SSI for CHILDREN

1. Overview of Childhood Disability Standard Linda Landry, Esq. Disability Law Center SSI for CHILDREN

2. Supplemental Security Income Eligibility Overview - Children • Categorical Eligibility: Disabled. • Low income – Countable income less than the maximum payable to that individual. • Low Resources – Countable resources of less than $2000 for an individual and $3000 for a married couple. $4000 for child living in 1 parent family, $5000 for a child living in a 2 parent family.

3. SSI Eligibility Overview,Continued • Residence in U.S. for 30 days. • Citizen and/or alien status requirements for benefits payable after December 1, 1996.

4. SSI Eligibility Overview,Continued • SSI pays a monthly cash benefit depending upon the recipient’s categorical status and living arrangement. • The maximum monthly payment is set each January by the Social Security Administration.

5. SSI Eligibility Overview, continued • A portion of the income and assets of parents who live with the child will be deemed to the child to determine income and asset eligibility and payment amount.

6. SSI Eligibility Overview,Continued • Earliest possible payment date is the first of the month after the month of application. • Medicaid coverage is awarded automatically upon the award of disability and payment status.

7. Non-Citizen SSI Eligibility Criteria • Prior to 8/26/96 PRUCOL (Permanently Residing Under Color of Law) was the standard. Now eligibility is much more limited. • Eligibility depends on the immigrant’s status and date of entry into the U.S. Three basic groups of aliens.

8. (1) Noncitizens Receiving SSI on 8/22/96 • All noncitizens who were "receiving" SSI on 8/22/96 are "grandfathered" into the SSI program, as long as they meet at least PRUCOL and remain otherwise eligible.

9. (2) Noncitizens Who Entered Prior to 8/22/96 Eligible for SSI IF they: • were "lawfully present" on 8/22/96; AND • are now "qualified aliens;" AND • are now "disabled" or blind (regardless of age)

10. Definitions of “Qualified Aliens” & “Lawfully Present” • "QUALIFIED ALIENS" include legal permanent residents (including Amerasians), asylees, refugees, persons granted withholding of deportation (now called cancellation of removal), Cuban/Haitian entrants, persons granted parole status for a period of at least 1 year, and battered spouses with a pending or approved spousal visa or petition for relief under VAWA and whose need for benefits has a substantial connection to the battering and who no longer live with their batters. • "LAWFULLY PRESENT" means inspected & admitted to U.S. & no violation of terms of admission.

11. (3) Non-Citizens who Enter After 8/22/96 Must meet one of the following to be SSI eligible: • LPRs, BUT only those with 40 quarters of coverage AND after 5 years in the U.S.; OR • refugees, asylees and persons granted withholding of deportation, BUT ONLY for the FIRST 7 YEARS in those statuses; OR • honorably discharged veterans and active duty armed services personnel who are "qualified aliens" and their spouses and unmarried, dependent children.

12. SSI Definition of Disability for Children • The child must have a medically determinable physical or mental impairment or combination of impairments that results in marked and severe functional limitations and which can be expected to last in death or which has lasted or can be expected to last for at least 12 months.

13. SSI Disability Analysis for Children • Medical (MD) documentation of mental and/or physical conditions or illness, • That have lasted or expected to last at least one year, and • That result in marked and severe limitations in age appropriate function (mental and/or physical)

14. SSI Disability Analysis for Children, continued • SSA first considers whether the medical criteria in its medical listings are met. • If the medical criteria are not met, SSA does an individualized assessment of the child’s ability to function in age appropriate manner. SSA compares the child’s functioning to that of an average child of the same age without a disability.

15. Sequential Analysis of SSI Disability for Children • Step1: Is the child engaging in SGA? • Step 2: Does the child have a “Severe” Impairment? • Step 3: Do the child’s impairments meet or medically equal the severity of a listed impairment? If not, is impairment severity functionally equivalent to the severity of a listed impairment?

16. Step 1: Substantial Gainful Activity (SGA) • Substantial = performance of significant productive physical or mental duties. • Gainful = work usually done for pay or profit, whether or not it's realized. • Significant duties = activities with economic value. One’s own household tasks, and non-paying work on hobbies, training, school, clubs, social programs, etc. does not constitute SGA in and of itself.

17. SGA, continued • Look at average gross monthly earnings. If countable gross earnings go over threshold, SGA is presumed. • SGA threshold changes every year. In 2007, SGA presumption threshold is $900/month. • If self-employed, look at net income after business deductions; value of work to business.

18. There’s More to SGA than the Numbers • Unsuccessful Work Attempts (UWA) are not SGA. UWA if work stops or earnings go below SGA due to impairment or removal of special conditions within 3 - 6 months. • Countable earnings may be reduced by: • Subsidies and special conditions, and • Impairment Related Work Expenses

19. Step 2: Severe Impairment • Child’s impairment(s) must result in more than minimal functional limitations. • SSA must consider all the child’s impairments together, even if none would have more than a minimal functional effect separately.

20. Step 3: The Listings of Impairments • SSA listings divide the body into 14 body systems. • The medical criteria described for impairments within each body system presume functional limitations that meet the disability standard for children. • Eligibility for SSI requires evidence that the child’s impairments, meet, medically equal or functional equal the severity of a listed impairment.

21. Step 3: The 14 Listed Body Systems • Growth impairments, §100.00; Musculoskeletal system, §101.00; Special senses and speech, §102.00; Respiratory system, §103.00; Cardiovascular system, §104.00; Digestive system, §105.00; Genito-Urinary system, §106.00; Hemic and lymphatic system, §107.00;Skin Disorders §108; Endocrine system, §109.00; Multiple body systems, §110.00; Neurological, §111.00; Mental disorders, §112.00; Neoplastic diseases, malignant, §113.00; Immune system (including HIV/AIDS), §114.00.

22. Step 3: Medically Meeting a Listed Impairment • A child's impairment meets a listing only when it manifests the specific findings described in the medical criteria for that listing. This is shown by comparing the symptoms, signs, and laboratory findings of the impairment with the corresponding criteria shown for the listing.

23. Step 3: Example of a Listed Impairment • 107.05 Sickle Cell Disease with: • A. Recent, recurrent severe vaso-occlusive crises; or • B. A major visceral complication in the 12 months prior to application; or • C. A hyperhemolytic or aplastic crisis w/in 12 months prior to application; or • D. Chronic, severe anemia with persistence of hematocrit of 26% or less; or • E. Congestive heart failure, cerebrovascular damage or emotional disorder as described in 104.02, 111.00 ff, or 112.00 ff.

24. Step 3: Medically Equaling a Listed Impairment • When a child's impairment or combination of impairments does not medically meet a listing, SSA must consider whether the child's impairment is medically equivalent to the severity of a medically analogous listed impairment. • This requires a well supported opinion from a doctor of the appropriate specialty

25. Step 3: Functionally Equaling a Listed Impairment • When a SSA determines that child’s impairment(s) does not medically meet a listed impairment and is not medically equally equivalent to an analogous impairment, SSA must consider whether the child’s impairment(s) is functionally equivalent to a listed impairment.

26. Step 3: Functionally Equaling a Listed Impairment, cont’d • Functional equivalence involves assessing the functional limitations caused by the child’s impairment(s) in terms of what the child cannot do, has difficulty doing, needs help doing, or is restrained from doing. • A child needs at least marked limitations in 2 functional domains or extreme limitations in one functional domain to meet the SSI disability standard for children.

27. Step 3: The 6 Domains of Function • Functional Equivalence Domains • Attending and completing tasks • Interacting and relating with others • Caring for oneself • Moving about and manipulating objects • Health and physical well-being

28. Step 3: Severity Level Required in the Domains • Disability eligibility requires marked level functional limitations in 2 domains or extreme functional limitations in 1 domain. • “Marked” means that the impairment(s) “seriously” affect the child’s ability to function in a domain. • “Extreme” means that the impairment(s) “very seriously” affect the child’s ability to function in a domain.

29. Step 3: Severity Level in the Domains, continued • Marked for children under age 3. SSA will generally find a "marked" limitation if the child is functioning at a level that is more than one-half but not more than two-thirds of chronological age when there are no standard scores from standardized tests in case record.

30. Step 3: Severity Level in the Domains, continued • Extreme for children under age 3. SSA will generally find an "extreme" limitation if the child is functioning at a level that is one-half of chronological age or less when there are no standard scores from standardized tests in case record.

31. Step 3: Other Factors SSA Must Consider • Symptoms such such as pain, fatigue, decreased energy, anxiety; • Age appropriate functioning; • Combined effects of multiple impairments • Ability to initiate, sustain and complete activities; • Amount of help or adaptations needed; • Effects of structured or supportive settings;

32. Step 3: Other Factors, continued • Unusual settings, i,e. testing settings; • Participation in early intervention and other school programs; • Impact of chronic illness and limitations that interfere with activities over time; • Effects of treatment, including medications and therapies.

33. Age 18 Redeterminations • Children must be redetermined under the adult disability standard within one year from the date they attain age 18. • SSA will notify a recipient that a review has begun and will invite the recipient to submit evidence of continuing disability. • Terminations are appealable and continuing benefits available through ALJ hearing if appeal filed within 10 days and continuing benefits requested at each step of appeal. Otherwise, appeal period is 60 days. • If lose on appeal, no overpayment if good faith belief that child was still disabled and eligible for benefits.

34. Evidence Issues in SSI Childhood Disability Cases • MD evidence preferred, often necessary to establish diagnosis. • Treating source evidence often due great weight. • BUT other evidence, especially from professional sources is very important, especially as to nature & severity of functional limitations.

35. Evidence Issues – Cont. Other Sources of Evidence: • Therapists • Nurse practitioners • Teachers • Early intervention providers • Counselors • Rehabilitation specialists • Lay sources: • family • friends

36. Evidence Issues – Cont. • Medical reports should: • Provide a diagnosis and prognosis • State the basis for opinion • Be specific about the nature and severity of resulting functional limits.

37. Evidence Issues – Cont. • For children, school evidence can be very important. • Obtain the complete school record. • Also, considering sending SSA’s Teacher Questionnaire to the child’s teachers.

38. Evidence Issues: The Bottom Line • All evidence should be considered. • Weight given depends on • Credibility, and • Support.

39. Appeal Process • Levels of appeal: • Reconsideration -to appeal application decision • Administrative Law Judge (ALJ) Hearing - to appeal Reconsideration • Appeals Council Review - to appeal ALJ decision • Federal Court • 60-day deadline for filing appeals; SSA assumes notices received within 5 days of date on notice. Can file late for good cause. • Forms at www.ssa.gov/online/forms.