Transcript Supplemental Security Income

Supplemental Security
Income
Federal benefits for disabled children
What is SSI?
 Monthly cash payment to low-income aged,
blind, and disabled persons
 Children with serious disabilities may receive
benefits (~1 million children in the U.S.
receive SSI benefits)
 Program is administered by the Social
Security Administration
Need for SSI
 Children with significant disabilities put extra
financial burdens on families –
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They need, at a minimum:
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More parental care, affecting a parent’s ability to
work steadily
More health care, which costs money even if the
patient has Medicaid or insurance (co-pays,
deductibles, uncovered items, transportation, time
off work for medical appointments, etc.)
Need for SSI
 SSI benefits can make significant difference
to a low-income family
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Automatic Medicaid
Extra money to help support child with
disability
 Additional financial resources can enhance
child’s overall health and wellbeing
Eligibility for children
 To be eligible for benefits, a child must:
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Meet administrative requirements
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Meet financial requirements
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Meet disability requirements
Administrative requirements
 Must apply – at Social Security Administration
(in Durham, corner of Pickett & Tower Blvd)
or call 1-800-772-1213 – and provide
required information
 Must be a U.S. Citizen or a qualified alien
(special immigration status)
 For children’s benefits, be under age 18
Financial eligibility
 Income limits –
 Based on a complicated formula taking into account
the monthly income of the parents and the number of
persons in the household
 very general example: One working parent, one
disabled child, one non-disabled child, might get some
benefit if monthly earnings are less than $3,267)
 Resource limits
 Family limit of up to $5,000 in accessible resources
(also based on complicated rules about what is and
isn’t “counted” and who is in the family)
Financial eligibility
 Maximum check amount is $710/month in 2013; increases with
federal cost-of-living adjustments
 If there is income that is “deemed available” to the child, that
amount is deducted from the maximum to get check amount
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Example: Child has $210 in income deemed available
to him
$710 (maximum for 2013)
-210
$500 monthly SSI benefit
Disability standards
 “Disability” is a legal determination, not a medical one
 Basic disability requirement for a child:
 The child must have a physical or mental impairment,
or combination of impairments, that causes marked
and severe functional limitations; and
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The impairment(s) must have lasted, or be expected to
last, at least 1 year or result in death.
Disability evaluation
 SSA contracts with disability examiners to review medical
records of applicants and determine if they meet the legal
standard for disability
 The records of treating physicians are the most important
records, and are “accorded great weight” in the review
 SSA looks to physician’s records for documentation of disability,
not for an opinion about disability
 A supplementary letter from a doctor specifically addressing the
relevant disability standards is extremely helpful in establishing
eligibility for benefits
Three-Step Process
 Disability examiners go through a three-question
process to determine if a child is disabled.
 1. Is the child engaging in substantial gainful
activity?

“Substantial” means work activity that involves
significant physical or mental activities
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“Gainful” means resulting in income of $900/month
(gross minus impairment related work expenses)
 IF yes, then no eligibility
Three-step process
 2. Does the child have a severe impairment
or combination of impairments?
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The impairment or combination of impairment must
cause more than minimal functional limitations
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The impairments must be “medically determinable,”
i.e., established by medically acceptable clinical and
laboratory diagnostic techniques (i.e., not only by the
individual's statement of symptoms
 If no, then no disability
Three-step process
 3. Does the child’s impairment or
combination of impairments meet, medically
equal, or functionally equal a listing?
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“A listing” refers to one of a set of standards
created by SSA known more formally as “The
Listing of Impairments”
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Found at
http://www.ssa.gov/disability/professionals/blu
ebook/ChildhoodListings.htm
The “Listings”
 Organized by body systems
 Each listing includes
 introductory material with definitions
 instructions about how conditions must be documented
 Identification of various diagnoses that fit the category
 certain findings that must be included in medical
records
 Durational requirements
 Severity levels
Listing Categories
 Growth Impairment
 Skin Disorders
 Musculoskeletal System
 Endocrine System
 Special Senses and Speech
 Impairments that Affect
 Respiratory System
 Cardiovascular System
 Digestive System
 Genitourinary System
 Hematological Disorders
Multiple
Body Systems
 Neurological
 Mental Disorders
 Malignant Neoplastic
Diseases
 Immune System
Alternative eligibility
Impairments are:

“Medically
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equivalent to a listing”
Condition is of equal medical significance to a listed condition
 “Functionally
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equivalent to a listing”
Compares with other children in six domains (extreme limitation in
one domain; marked limitation in two domains)
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Acquiring and using information
Attending and completing tasks
Interacting and relating with others
Moving about and manipulating objects
Caring for self
Health and physical well being
Examples of disabling impairments
from the listings
 20/200 best corrected vision
 Birth weight of less than 1200 grams, or 1200 – 2000 grams and
small for gestational age
 Epilepsy, with more than one episode of convulsive epilepsy per
month, either daytime episodes or nocturnal episodes that affect
daily activities
 Full scale IQ of 59 or less; full scale IQ of 60-69 with another
significant impairment
 Sickle cell disease, with chronic, severe anemia documented
with hermatocrit of 26 percent or less
Examples of disabling impairments
using alternative eligibility
 Diagnosed ADHD, with marked deficiencies in academic
functioning (4 -6 grades behind), needing directions repeated,
and chronic rule breaking activities, reflecting marked
impairments in acquiring and using information, and interacting
and relating with others.
 Esophagitis, with physical aggression, poor frustration tolerance,
inability to sustain attention, distractibility, immaturity reflecting
marked impairments in interacting and relating with others and
attending and completing tasks
Comparison cases
 Asthma – disabled
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attacks requiring physician intervention, in spite of
prescribed treatment, occurring at least once every 2
months or at least six times a year, with a duration of at
least a year
 Asthma – not disabled
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Only seasonal attacks, chest x-ray shows essentially
normal findings, on exam, lungs were clear, and
showed normal air entry, child participates in physical
activities without difficulty
Comparison cases
 Juvenile diabetes mellitus – disabled
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Insulin dependent diabetes, with widely ranging blood sugar
levels, recurrent episodes of hypoglycemia, several
hospitalizations, coupled with an adjustment disorder with
anxiety
 Juvenile diabetes mellitus – not disabled
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No lab data showing blood sugar levels more than 2
standard deviations from the norm, no hypoglycemic
episodes resulting in coma or convulsions, no recent
hospitalizations, and child engages in a broad range of
typical activities
Disability appeal process
 Application
Collection and review of records by disability examiner
(takes 3 – 6 months)
Reconsideration
 A different disability examiner collects any additional records
and reviews (takes 3 – 6 months)
Hearing
 An opportunity to appear before an Administrative Law
Judge; can submit additional information; very beneficial to
get an attorney (takes 12 - 18 months)
Appeals Council
 A national review board reviews (12 months)
Judicial Review
 Review by federal court (forever)
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Disability Appeal Process
 Most likely times to win:
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At Initial application or at hearing stage (need to appeal!)
 Most likely way to win:
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Have a doctor involved from beginning, paying close attention
to listings and documenting medical records to match
requirements
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Have a doctor who is willing to support application, by
responding to request for information from the disability
examiner
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Have a doctor who is willing to work with applicant’s attorney to
produce appropriate documentation
 Docs: let the lawyer do the work!
 Talk to lawyer about case
 Help lawyer get access to all medical records
 Promptly review letter drafted by lawyer, make
corrections, sign, and return
Screening for legal problems
 Clinician should watch for children who are
significantly impaired or have serious diagnoses
(HIV, cerebral palsy, blindness, deafness, sickle cell
disease, leukemia)
 If family appears to be of low income (Medicaid
eligible), ask if parent knows about SSI
 If parent mentions SSI application, ask about results.
Advise an appeal; consultation with legal team
Take home points
 A child with disabilities in a low-income family may be
entitled to an important cash benefit known as SSI
 In order to get SSI, the child’s medical records must
reflect a condition that meets the legal definition for
“disabled”
 Many initially denied applications can become
successful with lawyer & doctor working together