Download - 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 – They need, at a minimum:
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 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:
Meet administrative requirements
Meet financial requirements
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
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
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 “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?
The impairment or combination of impairment must cause more than minimal functional limitations
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?
“A listing” refers to one of a set of standards created by SSA known more formally as “The Listing of Impairments”
Found at http://www.ssa.gov/disability/professionals/bluebook/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
Musculoskeletal System
Special Senses and Speech
Respiratory System
Cardiovascular System Digestive System Genitourinary System
Hematological Disorders
Skin Disorders
Endocrine System
Impairments that Affect MultipleBody Systems
Neurological
Mental Disorders
Malignant Neoplastic Diseases
Immune System
Alternative eligibility
Impairments are:
“Medically equivalent to a listing” Condition is of equal medical significance to a listed condition
“Functionally equivalent to a listing”
Compares with other children in six domains (extreme limitation in one domain; marked limitation in two domains)
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 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 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 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 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)
Disability Appeal Process Most likely times to win:
At Initial application or at hearing stage (need to appeal!)
Most likely way to win: Have a doctor involved from beginning, paying close attention to
listings and documenting medical records to match requirements
Have a doctor who is willing to support application, by responding to request for information from the disability examiner
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