Recent Changes in Children's SSI
by Cate McClain, M.D.

As part of the 1996 "Welfare Reform" legislation, Congress narrowed the criteria for SSI eligibility. Under the new definition, it will be more difficult for children with a combination of impairments to qualify if no single condition matches a specifically identified medical impairment on the eligibility criteria. In New Mexico, 7,020 children with disabilities are currently enrolled in the federal Supplemental Security Income (SSI) program. This program provides a modest monthly payment and automatic eligibility for Medicaid. Children are eligible for SSI if: a) they or their families have little or no income; and b) they have a medically determinable physical or mental impairment that has lasted or is expected to last at least 12 months or results in death. Eligibility will be reviewed for more than 300,000 children nationwide, approximately 1,700 children in New Mexico, to see if they still qualify for benefits. The Social Security Administration (SSA) believes that at least 135,000 children nationwide will no longer be eligible and many of these children will also lose their Medicaid. It is felt that most of the children affected will be those with certain mental impairments, such as less severe learning disabilities and behavior disorders.

Benefits provided by the SSI program are important to families to families whose children have diverse, extraordinary needs. The monthly payment is intended to provide for basic necessities, such as food, clothing, shelter and transportation, and the additional special needs of a child with a disability. Some families have used the added income to pay for elevated electric bills because of the use of a home ventilator, a van with a wheelchair lift, ramps or widened doorways, computers for children with limited speech, specially trained childcare providers, educational and recreational toys, and over the counter nutritional supplements.

To qualify for benefits now, a child must have "marked and severe functional limitations" from a physical or mental condition. To prove this, a child's conditions must be in Social Security's "Listing of Impairments". Other changes in the eligibility criteria include deleting the Individual Functional Assessment (IFA), a method previously used to assess a child's functional and developmental status and the deletion of maladaptive behavior as a separate area of functioning from the "Listing of Impairments." The childhood "Listing of Impairments" describe specific mental or physical conditions for each of the major body systems that SSA considers severe enough to prevent a child from functioning independently, appropriately and effectively in an age-appropriate manner. A "marked and severe limitation" is defined as a valid standardized developmental test score two or three standard deviations or more below the mean for the test, functioning less than two-thirds of their chronological age for children birth to three, or a limitation that interferes seriously with function that interferes seriously with functioning for children 3 to 18 years of age.

Families are requested to provide documentation of the child's medical condition and functional limitations. This documentation should consist of medical and "other" evidence. The signs, symptoms, laboratory tests or psychological tests documenting the child's impairment are considered medical evidence. Medical evidence is critical because SSA regulations state that the impairment must stem from a medical cause. "Other" evidence refers to educational and therapy reports, information from public and private social welfare agencies and statements from parents, friends, relatives, neighbors, or clergy about the child's functional limitations. From the review of the child's file, the reviewer needs to be able to determine the degree of limitation in the following areas: cognitive/communication, motor, social, responsiveness to stimuli (birth to one year of age), self-care activities (3 to 18 years). The reviewer must develop a "mental" picture of the child from reviewing the chart since they will not actually examine the child. They will be searching for clues in the medical and "other" evidence to answer the following questions:

1. Does this child function in the same way as typical children of the same age who do not have disabilities?
2. What is different about this child?
3. How long has the child had the condition and how long is it likely to last?

4. What kind of help, if any, does this child need to function like other children of the same age who do not have a disability?

If a child's SS eligibility is to be redetermined, their families have or will receive an initial letter from SSI stating that their child's eligibility will be reviewed. Within 30 days of receipt of this letter, their child's file, consisting of medical records and other evidence, will be reviewed to redetermine their eligibility status and the family will be notified of the decision. If benefits are denied, the family has 60 days to appeal but must appeal within 10 days if they want to continue to receive benefits during the appeal process. If the child had Medicaid because of receiving SSI, the Medicaid will also continue while the family appeals the SSI decision. Appeals can go through several layers, from a hearing before a Social Security administrative law judge (AL) to federal court. Many advocacy groups are encouraging families to seek legal counsel when they enter the appeal process. The benefits receiving during the appeal process are considered "overpayment" and will need to be paid back to SSI unless the family can show that they appealed the denial of SSI benefits "in good faith". Medicaid coverage will end when SSI benefits stop if the child does not meet the state's income guidelines for Medicaid.

While SSI eligibility criteria has narrowed, SSA intends to support children and families it they meet the outlined criteria. If you know a child about whom the following are true, they most likely will be eligible for their family to receive SSI:

• Require intensive OT, PT, SLP, Psychological Counseling
• Failure to meet developmental milestone
• Unable to accomplish major activities of daily living in an appropriate way in the expected time frame
• Frequent absences from school
• Have a need for structured environment to maintain functioning (special classroom, constant assistance, residential facilities)
• Unable to participate in sports, or extracurricular activities due to physical or mental illness
• Unable to routinely complete classroom work
• Have frequent serious conflicts with family or peers
• Have a terminal illness

Changes in SSI eligibility criteria could have a major impact on a family's income and on their child's health coverage. Families will need assistance from their health care provider in gathering documentation that clearly describes their child's functional disability, as well as emotional support, through a possibly lengthy and stressful appeal process.