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