What you need to know about Supplemental Security Income (SSI)

For many, social security can very confusing. For parents of children with special needs needs there is something called Supplemental Security Income (SSI). This article will attempt to be an in-depth guide on Social Security and how it can effect your family.

What is the Difference Between SSI and the Social Security Disability Insurance program SSDI?

We can simplify the difference between the two programs real quickly---SSDI (Social Security Disability Insurance (“SSDI”) pays benefits to individuals and certain members of their family if they are "insured," meaning that you worked long enough and paid Social Security taxes.) does not apply to children with disabilities. The terms are sometimes thrown around interchangeably, but have very different criteria and applications. This article will only focus on Supplemental Security Income (“SSI”) payments to disabled individuals under the age of 18. There are programs for income payments to disabled individuals over the age of 18, but those rules and regulations will not be discussed herein. The entire Social Security Act (42 U.S.C 1381) (the “Act”), and the administration of the voluminous regulations and statutes are far too voluminous and complex to address in an article of this type, when books have been written on the topic.

The Program

The Social Security Administration (“SSA”), which has offices in most major U.S. cities, administers the program, amongst other unrelated programs, that provide financial benefits based on disability—this is commonly referred to as the SSI program or Title XVI of the Act (Title XVI appears in the United States Code as §§1381-1383f, subchapter XVI, chapter 7, Title 42. Regulations with respect to this Title XVI are contained in chapter III, Title 20, Code of Federal Regulations.) (hereinafter “SSI” and “Title XVI” will be used interchangeably). The Act and SSA's implementing regulations prescribe rules for deciding if an individual is "disabled." SSA's criteria for deciding disability may differ from the criteria applied in other Government and private disability programs. The child’s parents or guardian’s income and resources must be limited for the child to qualify for benefits.

How is “Disability” Defined for Children?

Under Title XVI, 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. (See Title 20, Sec. 1614, [42 U.S.C. 1382c]).

What is a "Medically Determinable Impairment"?

The regulations define a medically determinable physical or mental impairment as an impairment that results from anatomical, physiological, or psychological abnormalities, which can be shown by medically acceptable clinical and laboratory diagnostic techniques. The medical evidence must establish a physical or mental impairment consisting of signs, symptoms, and laboratory findings-not only by the individual's statement of symptoms. (See Title 20, Sec. 1614, [42 U.S.C. 1382c]. This is the area that causes the most contention during the application process. The current eligibility standards are based on medical, technological, and vocational data from over 30 years ago. (See, The Fake Fix for Disability Insurance, Koenig, Andy, The Wall Street Journal, November 11, 2015).

Medical Treaters

A treating source is a claimant's own physician, psychologist, or other acceptable medical source who provides or has provided the claimant with medical treatment or evaluation and has, or has had, an ongoing treatment relationship with the claimant. The treating source is usually the best source of medical evidence about the nature and severity of an individual's impairment(s). If an additional examination or testing is needed, SSA usually considers a treating source to be the preferred source for performing the examination or test for his or her own patient. The treating source is neither asked nor expected to decide whether the claimant is disabled. However, a treating source will usually be asked to provide a statement about an adult claimant's ability, despite his or her impairments, to do work‑related physical or mental activities or a child’s functional limitations compared to children the same age who do not have impairments. The SSA deems acceptable medical sources as:

licensed physicians (medical or osteopathic);
licensed or certified psychologists (includes school psychologists, for purposes of establishing mental retardation/learning disorder/borderline intellectual functioning);
licensed optometrists (for the measurement of visual fields or acuity);
licensed podiatrists (for purposes of establishing impairments of the foot, or foot and ankle, depending on the State);
qualified speech-language pathologists (for purposes of establishing speech or language impairments ); and
other individuals authorized to send us copies or summaries of the medical records from a hospital, clinic, or other health care facility.

Other Sources Used by the SSA in Making a Determination

Once the SSA has established the existence of an impairment(s), the SSA may also use evidence from other medical and non-medical sources to show the severity of the impairment(s) and how it affects the child's functioning. Other medical sources not listed above include, for example, physicians’ assistants, nurse practitioners, audiologists, and licensed clinical social workers. Non-medical sources include, for example, schools, public and private social welfare agencies, parents, guardians and other care givers. Educators and other school professionals (counselors, nurses, early intervention team members), in particular, can provide the specific, reliable information the SSA needs about how the child has functioned in school over the last 12 months. This information gives insight into the child's day-to-day functioning, which is very important in determining childhood disability.

The Disability Determination Process

Most disability claims are initially processed through a network of local Social Security field offices and State agencies (usually called Disability Determination Services, (“DDS”). Subsequent appeals of unfavorable determinations may be decided in the DDSs or by administrative law judges in SSA's Office of Disability Adjudication and Review (“ODAR”). Determining whether a child is disabled under SSI regulations is a collaborative effort among Federal and State officials.

Social Security Field Offices

SSA representatives in the field offices usually obtain applications for disability benefits, either in person, by telephone, by mail, or via an online application process. 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 "claimant" is the person who is requesting disability benefits.) The field office is responsible for verifying nonmedical eligibility requirements, which may include age, employment, marital status, citizenship/residency and Social Security coverage information. For SSI eligibility, the field office verifies income, resources, and living arrangement information. The field office sends the case to a DDS for disability evaluation.

State Disability Determination Services

The DDSs, are State agencies responsible for developing medical evidence and rendering the initial determination on whether the claimant is or is not disabled or blind under the law. These State agencies are fully funded by the Federal Government. Usually, the DDS obtains evidence from the claimant's own medical sources. When the evidence is unavailable or insufficient to make a determination, the DDS will arrange a consultative examination (“CE”) to obtain additional information. The claimant's treating source is the preferred source for the CE; however, the DDS may also obtain the CE from an independent source. (See Part II, Evidentiary Requirements, for more information about CEs.) After completing its initial development, the DDS makes the disability determination. The determination is made by a two-person adjudicative team consisting of a medical or psychological consultant and a disability examiner. If the adjudicative team finds that additional evidence is still needed, the consultant or examiner may re-contact a medical source(s) and ask for additional information. The DDS returns the case to the field office after making a disability determination. The field office takes appropriate action depending on whether the claim is allowed or denied. If the DDS finds the claimant disabled, SSA will complete any outstanding non-disability development, compute the benefit amount, and begin paying benefits. If the claimant is found not disabled, the file is retained in the field office in case the claimant decides to appeal the determination. If the claimant files an appeal of an initial unfavorable determination, the appeal is usually handled much the same as the initial claim with the exception that a different adjudicative team in the DDS than the one that handled the original case makes the disability determination.

Consultative Examiners for the DDS

In the absence of sufficient medical evidence from a claimant's own medical sources, SSA, through the State DDS, may request an additional examination(s). These CEs are performed by licensed physicians (medical or osteopathic physicians), psychologists or, in certain circumstances, other health professionals such as optometrists, podiatrists, and speech-language pathologists. All CE sources must be currently licensed in the State and have the training and experience to perform the type of examination or test SSA requests.

Medicaid

In most States, individuals who qualify for SSI disability payments also qualify for Medicaid. States may refer to the Medicaid program by different names. The program covers all of the approved charges of the Medicaid patient. Medicaid is financed by Federal and State matching funds, but eligibility rules may vary from State to State.

CONCLUSION

It must bear repeating that this article is but a layman’s summary of one small part of a very complex governmental benefits system. It is always best to consult an attorney to determine whether your child qualifies for SSI, as the process can be arduous and the attorney can lead you down the path and away from the land mines that often appear.

Michael Dorfman