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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
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? 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 a
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. § a(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 a(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: 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, speech- language 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 Step #1: Is the child working (engaging in substantial gainful activity? Step #2: Does the child have a medically determinable impairment or combination of impairments that is severe? 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: bluebook/ChildhoodListings
The Listings for Children 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 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 – Unlike for adults, the asthma listing has a category that just considers the medicines the child has been prescribed and has been taking. Listing (c)(2).
Mental Health Listings – 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 cont’d With exception of Listings and , 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 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 , which is for children who have not yet attained age 1. These age groups are: Older infants and toddlers (age 1 to attainme nt of age 3) Children (age 3 to attainment of age 18) However, further guidance and age group delineations are found in Listing C 1, 2, 3, and 4, which is broken down into four age groupings: 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 a - 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.What activities is the child able to perform? 2.What activities is the child not able to perform? 3.Which activities are limited or restricted? 4.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 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 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 ChallengesBenefits May not understand Social Security disability in general and child’s SSI specifically Confusion over supports provided by SSI (cash assistance and health insurance) Source for medical documentation 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) Licensed optometrists (for the measurement of visual acuity and visual fields) Physical, Occupational & Rehabilitation Therapists Day Care Providers Neighbors Friends Clergy Psychiatric Social Workers Nurse Practitioners Welfare Agency Staff Qualified Speech-language pathologists (for the purposes of establishing speech or language impairment only) C.F.R § Physical, Occupational & Rehabilitation Therapists* Qualified Speech-language pathologists (for the purposes of establishing speech or language impairment only)* * Considered “Acceptable Medical Sources”
Identifying Medical Providers 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 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 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 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 Identify person in charge of records – Administrative staff, guidance counselor Contact Teacher – /phone –Include classroom and special education teachers) School Nurse –Medications, plans 504 Coordinator –Written 504 plan listing accommodations Local Homeless Coordinator/Liaison –Identify school staff member assigned
Questions and Answers Facilitated By: SAMHSA SOAR Technical Assistance Center Policy Research Associates, Inc.
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