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Home Page > Disability > Documenting Disability for Physicians

Physician’s Guide to Documenting Disability in Child SSI Claims

 

The federal Supplemental Security Income (SSI) program provides much-needed cash and Medicaid health insurance coverage for children with disabilities in low-income families. This information will explain the SSI program and its importance to your pediatric patients.

I. What is Supplemental Security Income (SSI)?

The U.S. Social Security Administration has several disability programs for adults and children that provide cash and health insurance benefits. The SSI program includes monthly cash benefits and (in New Jersey) Medicaid HMO insurance coverage to children who prove they have a disability and whose families have very low income and resources. The benefit must be used for the child’s needs. [Note: The SSI Program also applies to low-income seniors regardless of disability (age 65 or older) and to younger adults with disabilities.]

The SSI program countable resource limit is $2,000 for individuals or $3,000 for a couple. The maximum cash monthly SSI benefit for individuals not in institutions is currently under $730 in New Jersey. However, SSI cash benefits can be lowered if the family receives other income or assistance. The cash benefit is intended to be used for the child’s benefit, typically covering expenses for medical bills, reliable transportation to medical appointments, additional educational help, etc.

The child needs to prove disability under special SSI Program rules to qualify. Pediatric physicians often play an important role in documenting disability through their medical records and reports.

II. What is the SSI Program Standard for Disability?

Social Security considers children to have a disability if they have medically determinable impairment(s) that cause marked and severe functional limitations. The impairment(s) must be expected to last at least 12 months or result in death. Social Security employs a three-step process for deciding the disability portion of child SSI claims:

  • Step One: Is the child performing substantial gainful work activity?
    If yes, the claim is denied. If no, proceed to step two.
  • Step Two: Does the child have a "severe" impairment (must be more than a slight abnormality causing minimal functional limitation)?
    If no, the claim is denied. If yes, proceed to step three.
  • Step Three: Does the child have an impairment(s) that meets or equals the severity of a “listed impairment?”
    If no the claim is denied. If yes, claim is granted.

The “listed impairments” mentioned in step three include a list of medical conditions that Social Security considers disabling. A child who meets the medical criteria for one of those listed impairments meets the disability requirements for receipt of SSI benefits. See Listing of Impairments - Childhood Listings (from Social Security Online)

Physicians often play an important role in documenting whether children meet the listing criteria. Physician reports and medical records are often necessary for children to establish eligibility for SSI. Accurate and legible recordation of a child’s medical condition and the resulting functional limitations is crucial.

Children who fail to directly meet the medical requirements of a listed impairment can still prevail by proving medical or functional equality to the listing requirements. Medical equivalence to a listing can occur when a child’s condition does not appear in the list of impairments, but the medical findings are closely analogous to a listed impairment. Functional equivalence can occur if a child has a medical condition or combination of conditions that cause a marked limitation of age-appropriate function in two of the following domains, or an “extreme” limitation in one:

  • Acquiring and using information,
  • Attending and completing tasks,
  • Interacting and relating with others,
  • Moving about and manipulating objects,
  • Caring for yourself, and
  • Health and physical well-being.

The terms “marked” and “extreme” are somewhat nebulous, although Social Security provides some guidance. Marked impairments seriously affect the child’s ability to independently initiate, sustain, or complete age-appropriate activities. For children under age three, marked limitations are found if function is at two-thirds or less of chronological age if no standardized tests are available. If standardized tests are available, a marked limitation is between two standard deviations and less than three standard deviations below the norm.

Extreme limitations very seriously affect ability to independently initiate, sustain, or complete age-appropriate activities, although it does not require a total lack of function. For children under three years old, extreme limitations mean they function at one-half of chronological age or less if no standardized testing is available. If standardized tests are available, an extreme limitation is the equivalent of three standard deviations or more below the norm.

Social Security considers medical and school records when making its decisions, as well as parent reports. However, any functional limitation found must be reasonably related to a medically documented condition.

When assessing how severe a limitation is, the standard of comparison is other similarly aged children with no impairments. If special conditions are necessary for the child to function normally, the child may still be found to have a serious impairment. Example: A child with attention deficit disorder who functions normally in a one-on-one teaching environment, but who could not function in a normal-sized classroom.

Single medical conditions can cause deficits in multiple domains of function. For example, a pain-producing condition like neuropathy may affect limb function (moving about and manipulating objects). The pain and/or prescribed medication may also distract the child and affect other domains (acquire and use information, attend and complete tasks). Pain may also make the child irritable around others (interacting and relating with others). Accurate and thorough documentation of reported symptoms can be important to ensure a proper assessment in such cases.

III. What Can Physicians Do to Help?

Physicians can assist patients by providing appropriate documentation when needed. Often this includes providing reports. Without such support, many deserving claims would be lost since the child has the burden of proving the disability. Social Security will typically not accept a physician’s report that a child is disabled unless it contains certain information. Physicians can efficiently and effectively document a patient’s medical condition(s) for Social Security by including the following information in a narrative medical report:

  • The length of treatment relationship and frequency of examination. Social Security will typically grant more weight to a physician’s opinion if there is a significant history of treatment.
  • Specialty and experience of medical provider. Specialist’s opinions are entitled to more weight in their area of specialty.
  • Diagnosis and prognosis, including the basis for each.
  • Opinion about whether the child’s medical condition satisfies one of the “listings.” A physician can review the listing that corresponds with the child’s condition and report if the requirements are met.
  • Signs and symptoms: The more detail here the better. Any available information on the frequency, duration, and severity of signs and symptoms should be included.
  • Functional limitations in various domains. The physician can document functional limitations that are reasonable and consistent with the child’s medical conditions in each of the six “domains” listed above. If a medical condition causes marked limitations in at least two domains, or extreme limitations in one, the patient will normally be considered disabled. If possible, estimate the degree of limitation in each functional domain, using a same-aged child with no limitations as a comparison. For information on what is considered normal, age-appropriate function in each respective domain, use the links in the resource section below.
  • Medical basis for findings. Treating medical providers play an important role in “connecting the dots” for Social Security. Social Security will usually give more weight to the opinion of a provider that includes an explanation of what medical condition(s) caused a patient’s reasonable claimed limitations, along with supporting medical evidence.
  • Expected duration. Social Security requires that the condition must be expected to last at least 12 months or result in death.

Sometimes Social Security or an advocate will supply a report form for the convenience of the physician. While these vary in length, they are designed to make the physician’s job easier by using blanks and checklists to shorten the time needed to complete the report. These forms are useful but generally are not as effective as a narrative unless the physician makes special effort to explain in writing the medical basis for the opinions given on the form.

In conclusion, the SSI program provides vital medical coverage and cash assistance to low-income children with disabilities. Physicians can assist their patients in obtaining these benefits by documenting their medical conditions and providing relevant information in reports forms or narrative reports.

IV. Resources for Further Information

Disclaimer: The description of the SSI program contained in this document is basic and summarized for brevity’s sake. The complete rules are much more complex and exceptions exist to some of the rules stated. Please consult with an attorney for legal advice in any particular case.

This information last reviewed 3/29/12

 

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