Childhood Disability Benefits (SSI): Ensuring Support for Children in

Poverty

Objectives:At the end of this training, you should . . .

Know what Child SSI is,

Understand SSA standards for determining eligibility for Child SSI, and

Know how to help patients navigate the SSI application and appeal process.

Poverty and Health

Poverty causes poor health People with a higher socioeconomic

status have better health outcomes. “Psychological, social and economic

adversity in childhood can have long-term consequences for health.”

Benedict, Meredith et. al., Social Determinants of Health Disparities and the Role of Law, Poverty Health and Law, 2011.

Poor health causes poverty

Medical conditions, disabilities, and overall poor health affect ability to maintain employment and manage expenses.

Illness and medical bill contributed to 62% of US bankruptcies in 2007

Ohio access basics, Health Policy Institute of Ohio, October 2012

Poverty in our Community Kids Count Data Center (datacenter.kidscount.org)

Ohio 23.1% of Ohio Children are living in poverty 44.9% of Ohio Children qualify for Public

Health Insurance

Lucas County 29% of Lucas County are living in poverty 53% of Lucas County children are enrolled in

Public Health Insurance

 

Housing &

Utilities

Stability &

Safety

ImmigrantStatus

Health Care

Access

Child and Family Health

School Discipline &

Special Education

Employment & Income

Food

Wide Range of Factors Influence Child Health

Challenges for Families in Poverty with Children with Disabilities

Trouble holding a job

Making ends meet

Meeting child’s disability-related needs

Access to supports

Stress on the family

What is SSI?

Supplemental Security Income (a.k.a. Title XVI, Childhood Disability Benefits)

A federally financed and administered needs-based program for adults and children with disabilities in poverty.

Children’s SSI program created in 1972

Purpose of Child SSI: Where does SSI fit in?

To assure a minimum level of income for children who are blind or disabled and who do not have sufficient income and resources to maintain a standard of living.

Financial support to children in poverty when their disability may require that they receive additional supports, supervision, care. (i.e. Parent may not be able to maintain work due to child’s needs.)

Who is eligible for Child SSI?

A child with a disability A child under age 18 will be considered disabled if he or she has a

medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.

Not engaged in substantial gainful activity (working)

Low income

Process for Applying for SSI

Applicants can apply in person at the local SSA field office, by phone, mail, or online.

The application and related forms ask for a description of the claimant's impairment(s); names, addresses, and telephone numbers of treatment sources; and other information that relates to the alleged disability.

The field office is responsible for verifying nonmedical eligibility requirements, which may include age, employment, marital status, citizenship/residency and Social Security coverage information, and additionally, for SSI eligibility, income, resources, and living arrangement information.

Application Process Continued

Initial Application sent to Disability Determination Services (DDS).

If denial of Initial application, claiming can file a request for reconsideration within 60 days.

If reconsideration denied, claimant can request an Administrative Hearing in 60 days. Hearing are before an administrative law judge in SSA's Office of Disability Adjudication and Review. (This process can take years!)

Determining Child Eligibility for SSI

Social Security will look at whether the child meets, “medically equals,” or “functionally equals” the Child Listings of Impairments

For older children, Social Security will look to whether the child is working.

The child’s functional ability is compared to other children of similar ages

The Childhood Listings

Listing of Impairments - Childhood Listings (Part B)

The following sections provide medical criteria for the evaluation of impairments of children under age 18 (where criteria in Part A - Adult listings do not give appropriate consideration to the particular disease process in childhood).http://www.socialsecurity.gov/disability/professionals/bluebook/ChildhoodListings.htm

If a child meets a listing, the child qualifies for SSI (Assuming the child also meets the income and work requirements)

Case Study: Asthma

Johnny is 8 years old and was diagnosed with asthma at age 5. He and his mother live in a run-down inner city home with a leaky roof. Johnny’s Mom would love to move them to a place that is less damp and moldy, but she has been unable to save up first month’s rent and a security deposit.

Johnny’s asthma is not well-controlled. He uses an albuterol nebulizer on a twice daily basis, but his Mom has confided to you that she has caught him sometimes pulling off the mask because he finds it uncomfortable and doesn’t like the “hopped up” way that the medicine sometimes makes him feel after a breathing treatment. She has begun watching him for the entire treatment to make sure that he keeps the mask on.

Case Study: Asthma (cont’d.)

During the last year, he has been treated for asthma attacks at the emergency room 5 times. The first three times all occurred during one month last winter. After the third time, Johnny’s doctor prescribed a 7-day course of corticosteroids to try to stop his persistent low-grade wheezing. After each of the other two attacks (one in May and one in September), Johnny’s doctor has prescribed 5-day courses of corticosteroids.

Johnny’s Mom has applied for SSI on the basis of his asthma. She is hopeful that he will be approved so that they will have enough money to move to a nicer apartment, which might improve Johnny’s asthma.

Can Johnny meet the listing for asthma 103.03?

How can you help?

Case Study: Asthma (cont’d.)

Check the listing: 103.03 Asthma

Help Mom gather relevant medical records

Encourage Mom to appeal if denied

Be willing to complete questionnaires and/or submit a detailed letter to SSA indicating how child’s symptoms in light of the listing. (In other words, SSA may need you to lay out the symptoms which meet the listing.)

Childhood functional domains

For children, the medical evidence should address the child’s physical health and well-being functional limitations in learning, motor functioning, performing self-care activities, communicating, socializing, and completing tasks (and, if a child is a newborn or young infant from birth to age 1, responsiveness to stimuli)

Child’s disability benefits

In Functional Limitations, Social Security looks for Marked and Extreme differences: “Extreme” = impairment interferes very

seriously with ability to independently initiate, sustain or complete activities, or more than marked.

“Marked” = more than moderate but less than extreme; serious interference with ability in independently initiate, sustain, or complete activities.

Case Study: ADHD

Diagnosis: ADHD, ODD, Mood disorder, and speech delays;

Identified as a student with an Emotional Disturbance eligible for special education services; While attending kindergarten: removed and placed in an inpatient program at Kobacker Center for three days for endangering others at the school;

Attended five different elementary schools and just completed her second year of second grade – regularly sent to office and suspended;

Receiving mental health service at Zepf Center; Patient at University Pediatrics at UT, prescribed Adderall;

Denied SSI at initial application and reconsideration phase.

Case Study ADHDPhysician Involvement

Pediatrician referred case to the MLPC

Pediatrician took the time to complete a Functional Capacity Assessment for the child

MLPC prepared case for Administrative Law Judge Hearing: Gathering medical, mental health and educational records Preparing pre-hearing brief Representing child at hearing

Case Study ADHDTaking case through the functional domains

Acquiring and Using Information

Attending and Completing Tasks

Interacting and Relating with Others

Caring for herself

Moving about and manipulation objects

Physical health and well-being

Case Study ADHDHImpact of physician involvement

ALJ stated in favorable decision: The claimant’s primary care physician, submitted a functional capacity

assessment. She noted that she has treated the claimant for her ADHD and ODD for 3 years and that the claimant has exhibited hyperactivity and impulsivity during office visits. Based on her clinical observations, Dr. opined that the claimant had slight to serious limitations in her ability to acquire and use information, obvious to very serious limitations in attending and completing tasks, and obvious to very serious limitations in interacting and relating to others. The undersigned affords great weight to the Dr. opinions because they are consistent with the medical records as a whole.

Periodic Review of Eligibility and Cessation

Continuing Disability Reviews for Children's SSI Cases

Any child who receives SSI disability benefits will have their eligibility reviewed at least once every three years.

At age 18 – the child’s eligibility is reviewed using adult SSI standards.

The CDR process for children occurs as follows…

Periodic Review of Eligibility and Cessation

STEP ONE: Has there has been medical improvement in the child's impairments?

SSA defines medical improvement as any decrease in the medical severity of [the] impairment(s) which was present at the time of the most recent favorable decision . . .20 CFR 416.994a(c).

If there has been NO medical improvement, the child is still disabled and entitled to benefits.

If there has been medical improvement, go to STEP TWO.

Periodic Review of Eligibility and Cessation

STEP TWO: If there has been medical improvement, SSA determines whether the

impairment(s) the child had at the time of SSA's most recent favorable decision NOW meets or medically or functionally equals the severity of the listing it met at that time.

If the current impairment(s) still meets or equals the original listing, the child remains disabled and benefits will continue.

If there has been medical improvement and the child's impairment(s) no longer meets the listing that it met at the time of the last favorable decision, go on to STEP THREE

Periodic Review of Eligibility and Cessation

STEP THREE: SSA must consider whether the child's impairment(s) is

disabling under the new childhood disability standard, as it appears at 20 CFR 416.924.If the child's impairment(s) falls within the new childhood disability standard, disability benefits will continue.

If it does not, disability will cease. In determining whether a child is currently disabled at STEP

THREE, SSA conducts the following review:

Periodic Review of Eligibility and Cessation

Does the child have a severe impairment?If yes, go on to next step. If no, the child is not disabled.

Does the child's impairment(s) meet or equal any of the current listed impairments?If yes, the child remains disabled. If no, go on to next step.

Does the child's impairment functionally equal the severity of any listed impairment?If yes, the child is remains disabled. If no, the child is not disabled.

NOTE: There are a few exceptions in which disability may end, even if there has been no medical improvement. Advocates should review the regulations at 20 CFR 416.944a(e) and (f).

Rights upon Cessation

Notice

Reconsideration

Hearing

Physician’s Role in Child SSI cases:

What can you do to help? Discuss case and process with patient. Encourage patient to cooperate

with attending SSA physician appointments, providing relevant documents and signing and returning forms from SSA.

Review Child SSI Listings Help gather medical records and identify relevant tests, assessments,

etc. Write a letter to SSA regarding condition, symptoms, severity, etc.

keeping in mind the listings. Be willing to complete an Functional Capacity Questionnaire

Opportunity for Systemic Advocacy

Review and comment on listings

Work with advocacy coalitions (asthma, autism, others?)

Resources

Disability Rights Ohio www.disabilityrights.ohio

The Ability Center of Greater Toledo: (419) 885-5733

Social Security Administration: http://www.socialsecurity.gov/disability/professionals/bluebook/ChildhoodListings.htm

edResourcesOhio.org

Medical Legal Partnership for Children: mlpc.ablelaw.org