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

1. Childhood Disability Benefits (SSI): Ensuring Support for Children in Poverty David Koeninger, Senior Attorney, Advocates for Basic Legal Equality, Inc. Kate Mitchell, Legal Director, Medical Legal Partnership for Children, Legal Aid of Western Ohio, Inc. Date: October 24, 2012

2. 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.

3. 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.

4. 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

5. Poverty in our CommunityKids 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

6. Wide Range of Factors Influence Child Health Food Housing & Utilities Employment & Income Stability & Safety Child and Family Health Health Care Access School Discipline & Special Education Immigrant Status

7. 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

8. What is SSI? • SSI = Supplemental Security Income (a.k.a. Title XVI, Childhood Disability Benefits) • SSI = A federally financed and administered needs-based program for adults and children with disabilities in poverty. • Children’s SSI program created in 1972

9. 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.)

10. 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

11. 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.

12. 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!)

13. 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

14. 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)

15. 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.

16. 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?

17. 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.)

18. 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)

19. 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.

20. 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.

21. 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

22. 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

23. 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.

24. 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: • 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.

25. Periodic Review of Eligibility and Cessation (cont’d.) • 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 • 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:

26. Periodic Review of Eligibility and Cessation (cont’d.) • 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).

27. Rights upon Cessation • Notice • Reconsideration • Hearing

28. 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

29. Opportunity for Systemic Advocacy • Review and comment on listings • Work with advocacy coalitions (asthma, autism, others?)

30. 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.lawolaw.org Resources