Transcript OKLAHOMA COLLABORATIVE MENTAL HEALTH REENTRY …

SSI for Children
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SSI for Children
Presented by:
SAMHSA SOAR Technical Assistance Center
Policy Research Associates, Inc.
Under contract to:
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Welcome!
Deborah Dennis
National SOAR Project Director
Policy Research Associates, Inc.
Delmar, NY
Webinar Instructions
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Muting
Recording availability
Downloading documents
Evaluation
Question instructions
Agenda
SSI
for Children: Determining Childhood Disability
Randi Mandelbaum, Clinical Professor of Law and Director Child
Advocacy Clinic, Rutgers School of Law, Newark, NJ
Working
with Medical Providers and Other Sources
in Child SSI Claims
Pam Heine, SAMHSA SOAR Technical Assistance Center,
Policy Research Associates, Inc.
Questions
and Answers
SAMHSA SOAR TA Center
Purpose
 SOAR was originally developed for adults
experiencing homelessness with serious
mental illness and co-occurring substance
use disorders
 SOAR critical components have been applied
to successfully represent children and other
groups in some SOAR programs around the
country
How do Children Qualify for SSI?
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Four main criteria considered:
– Disability
– Income
• Parent/household income
– Resources
• Parent/household resources
– Citizenship/Immigration status
SSI for Children:
Determining
Childhood Disability
Randi Mandelbaum
Clinical Professor of Law and Director
Child Advocacy Clinic
Rutgers-Newark School of Law
How is Disability Defined?
 Separate definition from that of adults.
 A child (under 18) is considered to be
disabled if:
 “he/she has a medically determinable physical or
mental impairment, which results in marked and severe
functional limitations and which can be expected to
result in death or which has lasted for a continuous
period of not less than 12 months.”
42 U.S.C. § 1382c(a)(3)(C)(I)
Overarching Question:
How does the child’s functional abilities
compare to the functional abilities of a child
of the same age who does not have the
physical and/or mental impairments?
Look at all aspects of 20 C.F.R. 416.924a
General Guidelines for Case
Practice
 SSA must consider all relevant information
– both medical and nonmedical
 But must have some evidence of a
medically determinable impairment
Does the child need extra help?
 More help than a child of the same age
without an impairment would need
 Nature and extent of any adaptations (i.e.,
necessary assistive devices or technology)
Focus on…
 Whether there are factors present which mask the
functional limitations or which cause or
exacerbate the functional limitations.
 The standard of comparison (ex. special education
teacher stating that the child is doing well – as
compared to what one would expect of this child,
as compared to other children in the special
education class, or as compared to children who
do not have impairments)
20 C.F.R. § 416.924a(b)(3)
Must also consider:
 Effects of treatment, including medication
side effects (e.g., drowsiness, nervousness,
pain, nausea, impact on appetite)
 Frequency of treatment
 How long the child will need treatment
 Does treatment interfere with the child’s
participation in typical activities
Does the child need a structured
or supportive setting?
20 C.F.R. 416.924a(b)(5)(iv)(B) defines structured or
supportive setting as follows:
 The child’s home in which family members or other
people (nurses or home health workers) make adjustments
to accommodate the child’s impairments
 The child’ classroom in school, whether it is a regular
education classroom in which the child is accommodated
or a special classroom
 A residential facility or school where the child lives for a
period of time
Structured or Supportive Setting cont’d
REMEMBER structured or supportive settings may
minimize signs and symptoms of child’s impairments
 SSA should assess the child’s need for a structured setting
and the degree of limitation in functioning he/she would
have outside the structured setting.
 Even if child is able to function adequately in the
structured or supportive setting, SSA must consider how
the child would function in other settings and whether
he/she would continue to function at an adequate level
without the structured or supportive setting.
Unusual Settings
 SSA recognizes that children may behave
and perform differently in unusual settings
(i.e., testing or one-on-one situations)
 But that this behavior should not be relied
upon in isolation in determining the severity
of functional limitations
 Must look to typical behavior
Treatment of Test Scores
 Cannot rely on any single test score alone.
 Can find that a child has a “marked” or “extreme”
limitation even if test scores are slightly higher than the
level required, if other evidence shows that the child’s
functioning is seriously or very seriously limited.
 If there is an inconsistency between test scores and other
evidence in the case record, SSA decision-makers must try
to resolve it.
 When SSA does not rely on test scores, it must explain the
reasons for doing so in the case record or decision.
Is the child receiving special education
or early intervention services?
Useful School Records:
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Referrals for evaluations
Evaluations and Reevaluations
IEPs or IFSPs
Progress updates and Therapy Notes
Incident or Disciplinary Reports
Report Cards
Attendance Records
Useful components of special
education/early intervention records
 How and why child was found eligible for
special education
 Type of special education program
 Related services (transportation, speechlanguage therapy, counseling, occupational
therapy, physical therapy, etc.)
 Evaluation summaries, present levels of
performance, strengths and weaknesses
 Annual educational goals
Additional components of special
education/early intervention records
 Extent to which student is not participating in
regular classroom and why (SE only)
 Behavior Intervention Plans (SE only)
 Transition Plans (for children 16 and older)
 Need for summer school (Extended School Year)
 Testing Accommodations (SE only)
 Modified graduation requirements (SE only)
Myth
If the child is in special
education, the child will
receive SSI benefits
FALSE
Caution about using school and EI
Records
• Individualized Education Program (IEP) or
Individualized Family Service Plan (IFSP)
eligibility does not automatically equal SSA
disability
• Records may not include diagnosis
• Report cards often contain A’s and B’s
(need to question basis of comparison)
Sequential Evaluation
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Step #1: Is the child working (engaging in
substantial gainful activity?
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Step #2: Does the child have a medically
determinable impairment or combination
of impairments that is severe?
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Step #3: Does the child impairment(s)
meet, medically equal, or functionally
equal the listings?
Step #1 – Substantial
Gainful Activity
Is the child working?
2013 SGA = $1040
Severity – Step #2
 Severity at Step #2 is defined as :
 “a slight abnormality or a combination of slight
abnormalities that causes no more than minimal
functional limitations.”
 Used to “weed out” children who do not have a
medically determinable impairment or whose
impairments do not impose more than mere
minimal functional limitations.
Step #3 – Meeting or Equaling the
Listings of Impairments
 Meeting
 Medically equaling
 Functionally equaling
 SSA Website:
www.ssa.gov/disability/professionals/
bluebook/ChildhoodListings
The Listings for Children
100.00
101.00
102.00
103.00
104.00
105.00
106.00
107.00
Growth Impairment
Musculoskeletal System
Special Senses and Speech
Respiratory System
Cardiovascular System
Digestive System
Genito-Urinary System
Hemic and Lymphatic System
The Listings cont’d
109.00
110.00
111.00
112.00
113.00
114.00
Endocrine System
Multiple Body Systems
Neurological
Mental and Emotional Disorders
Neoplastic Diseases/Malignant
Immune System
Contained within Appendix 1 of Subpart P of Part 404 of the Code
of Federal Regulations
Asthma Listing – 103.03
Unlike for adults, the asthma listing
has a category that just considers
the medicines the child has been
prescribed and has been taking.
Listing 103.03(c)(2).
Mental Health Listings – 112.00
 Mental impairments listing is very
extensive. There are 11 mental disorder
categories with subcategories.
 Nearly one-half of children who receive SSI
benefits have some type of mental disorder.
Listing 112.00 cont’d
 With exception of Listings 112.05 and 112.12, the
mental health listings are divided up into “A” and
“B” criteria. The “A” criteria are specific to the
diagnostic criteria of the given disorder. The “B”
criteria are the same for all of the mental health
categories and assess functional abilities.
 Must meet both “A” and “B”.
 The “C” criteria that is present in the comparable
adult listing (listing 12.12) is not present.
Areas of Functioning
“B” Criteria
 Motor Development (children under age 3)
 Cognitive/Communicative Function
 Social Function
 Personal Function (children 3 and older)
 Deficiencies in Concentration, Persistence,
and Pace (children 3 and older
“B” Criteria of Listing 112.00
 In defining the severity of functional limitations, two different
sets of “B” criteria, corresponding to two separate age
groupings, have been established, in addition to listing 112.12,
which is for children who have not yet attained age 1. These age
groups are:
 Older infants and toddlers (age 1 to attainment of age 3)
 Children (age 3 to attainment of age 18)
 However, further guidance and age group delineations are
found in Listing 112.00C 1, 2, 3, and 4, which is broken down
into four age groupings:
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Older infants and toddlers (age 1 to attainment of age 3)
Preschool children (age 3 to attainment of age 6)
Primary school children (age 6 to attainment of age 12)
Adolescents (age 12 to attainment of age 18)
Medically Equaling
A medical impairment or combination of
impairments is medically equivalent if the
medical findings are at least equal in
severity and duration to the listed findings.
Medical Equivalence cont’d
Medical equivalence may be argued in one of
three ways:
1. Child does not exhibit one or more of the specified
medical findings, or the child exhibits all of the medical
findings, but one or more is not as severe.
2. Child has an impairment that is not described in the
listings, but is closely analogous to a listed impairment.
3. Child has a combination of impairments, where no
individual impairment meets a particular listing, but the
combination of symptoms is closely analogous to a listed
impairment
Functional Equivalence
 20 C.F.R. 416.926a - Functional equivalence is
shown when an impairment or combination of
impairments causes the same disabling functional
limitations as those of a listed impairment.
 Do not need to connect the functional limitations
to any particular listing.
 Basis for functional comparisons is with the
activities of children the same age who do not
have impairments.
Looks to answer the following questions:
1.
2.
3.
4.
What activities is the child able to perform?
What activities is the child not able to perform?
Which activities are limited or restricted?
Where does the child have difficulty performing
activities?
5. Does the child have difficulty initiating,
sustaining, or completing activities?
6. What kind of help does the child need?
Six 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 Yourself
Health and Physical Well-Being
Domains cont’d
 Each of the domains, excluding health and
physical well-being contains age-appropriate
criteria for the following age groups:
 Newborns and young infants (up to age 1)
 Older infants and toddlers (1 – 3)
 Preschool children (3 – 6)
 School age children (6 – 12)
 Adolescents (12 – 18)
Social Security Rulings
 Went into effect in March 2009 - offer guidance
both broad and detailed on applying the functional
equivalence test
 SSR 09-1p (Determining Childhood Disability
Under the Functional Equivalence Rule--the
"Whole Child" Approach)
 SSR 09-2p (Determining Childhood Disability-Documenting a Child's Impairment-Related
Limitations)
Social Security Rulings cont’d
 09-3p Acquiring and Using Information
 09-4p Attending and Completing Tasks
 09-5p Interacting and Relating with Others
 09-6p Moving About and Manipulating Objects
 09-7p Caring for Yourself
 09-8p Health and Physical Well-Being
“Marked” and “Extreme”
 Must have “marked” limitations in at least
two domains or “extreme” limitations in at
least one domain.
 “Marked” and “Extreme” have the same
definitions for all of the domains, except the
domain of Health and Physical Well-Being.
“Marked” defined
 Interferes seriously with the child’s ability to
independently initiate, sustain, or complete
activities
 More than moderate, but less than extreme
 When standardized test scores are available, scores
that are at least 2, but less than 3 standard
deviations below the mean.
 For children under 3, if the child’s functioning is
at a level that is more than one-half, but less than
two-thirds, of the child’s chronological age.
“Extreme defined”
 Interferes very seriously with the child’s ability to
independently initiate, sustain, or complete
activities
 When standardized test scores are available, scores
that are at least 3 standard deviations below the
mean.
 For children under 3, if the child’s functioning is
at a level that is more than one-half of the child’s
chronological age or less.
Myths
It is easier to get SSI for
a child than an adult.
FALSE
Myths
If found eligible for SSI as a
child, the child will
automatically keep receiving
benefits as an adult.
FALSE
Myths
Retroactive SSI benefits for
children can be used the
same way as for adults.
FALSE
Working with Medical Providers and
Others in Child SSI Cases
Pam Heine, MSW, LSW
Policy Research Associates
SAMHSA SOAR TA Center
Delmar, New York
Working with Medical Providers
Challenges
Benefits
May not understand Social
Security disability in general
and child’s SSI specifically
Source for medical
documentation
Confusion over supports
provided by SSI (cash
assistance and health
insurance)
Broad source of knowledge
regarding child’s medical
history
May not understand how
diagnosis impacts child’s
functioning
Understands how diagnosis
impacts child’s functioning
Sources of Medical and
Other Evidence
Diagnosis (A Criteria) “Acceptable Medical
Sources”
Six Functional Domains
(Similar to Part B Criteria of adult mental
impairment listings)
Licensed physicians (medical or osteopathic
doctors)
Parents
Caregivers
Education Personnel
Licensed or certified psychologists (including
school psychologists)
Day Care Providers
Neighbors
Friends
Clergy
Psychiatric Social Workers
Nurse Practitioners
Welfare Agency Staff
Licensed optometrists (for the measurement of
visual acuity and visual fields)
Physical, Occupational & Rehabilitation
Therapists
Qualified Speech-language pathologists (for
the purposes of establishing speech or
language impairment only)
Physical, Occupational & Rehabilitation
Therapists*
C.F.R § 416.913
* Considered “Acceptable Medical Sources”
Qualified Speech-language pathologists (for the
purposes of establishing speech or language
impairment only)*
Identifying Medical Providers
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Wide range of providers
– Specialists, Mental Health Providers, Speech Therapists, etc.
Providers who are not local
– Schools, Clinics, Specialists, Medical Homes
Medicaid HMO Care Coordinator
– Access electronic medical records, transportation, referrals
Pediatric provider may be “hub” of treatment
Social Work Services
– Agencies supporting children with complex diagnosis,
information on diagnosis, names of providers, medical history
SSA record
– Find out about prior filings, list of providers, diagnoses,
records obtained
Obtaining Documentation
from Other Providers
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Consider entire array of providers
– Medical specialists: Speech, Occupational,
and Physical Therapist
– Mental Health Providers
– Psychologists, Therapists, Social Workers
– Home Health Services: Visiting Nurses,
home health aides, respite caregivers
Effective Communication with
Providers
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If possible, set up a conversation to
discuss the medical providers impression
and advice before requesting report and
/or testing
Provide information needed to properly
assess the child
Convey your needs regarding
documentation for the claim
Effective Communication with
Providers
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Personal communication- phone/fax letter preferred
Identify your interest
Be conversant with the medical issues
Format request to facilitate response
– Focus on functionality which existing records might not
address
– Series of questions
– Narrative: provide direction- what specific information are you
seeking
– Draft of Medical Summary Report- provide draft to provider
Accessing Educational Records
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Identify person in charge of records
– Administrative staff, guidance counselor
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Contact Teacher
– Email/phone
– Include classroom and special education teachers)
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School Nurse
– Medications, plans
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504 Coordinator
– Written 504 plan listing accommodations
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Local Homeless Coordinator/Liaison
– Identify school staff member assigned
Questions and Answers
Facilitated By:
SAMHSA SOAR Technical Assistance Center
Policy Research Associates, Inc.
For More Information on SOAR
Visit the SOAR website: www.prainc.com/soar
SAMHSA SOAR TA Center
Policy Research Associates, Inc.
518-439-7415
[email protected]
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Twitter: @soarworks