1. Supplemental Security Income Federal benefits for disabled children

2. 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

3. Need for SSI Children with significant disabilities put extra financial burdens on families – They need, at a minimum: More parental care, affecting a parents 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.)

4. 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 childs overall health and wellbeing

5. Eligibility for children To be eligible for benefits, a child must: Meet administrative requirements Meet financial requirements Meet disability requirements

6. 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 childrens benefits, be under age 18

7. 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 isnt counted and who is in the family)

8. 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

9. 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.

10. 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 physicians 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

11. 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

12. 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

13. Three-step process 3. Does the childs 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/blu ebook/ChildhoodListings.htm http://www.ssa.gov/disability/professionals/blu ebook/ChildhoodListings.htm

14. 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

15. Listing Categories Growth Impairment Musculoskeletal System Special Senses and Speech Respiratory System Cardiovascular System Digestive System Genitourinary System Hematological Disorders Skin Disorderskin Disorders Endocrine System Impairments that Affect Multiple Body Systems Impairments that Affect Multiple Body Systems Neurological Mental Disorders Malignant Neoplastic Diseases Malignant Neoplastic Diseases Immune System

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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)

22. 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 applicants 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

23. 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

24. 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 childs 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