Supplemental Security Income: Progress Made in Implementing Welfare
Reform Changes; More Action Needed (Letter Report, 06/28/1999,
GAO/HEHS-99-103).
The Social Security Administration (SSA) has made significant progress
in implementing welfare reform's requirements for assessing children's
continuing eligibility for benefits. It has finished almost all of the
one-time redeterminations required for children who had been receiving
benefits when welfare reform was enacted, and it has done continuing
disability reviews when required on low-birth-weight babies and
18-year-olds. It also has a plan to ensure that all required continuing
disability reviews for children under 18 whose conditions are likely to
improve will be completely underway by 2000. However, SSA has not yet
decided whether any revisions are necessary to the interim final
regulations that were issued to implement the law's new definition of
disability for children, and it has made little progress in updating its
medical listings for childhood impairments. Although it has taken steps
to accomplish the update, such as recruiting staff, it has not set a
timetable to accomplish the update. Until SSA completes this initiative,
its medical listings for childhood impairments will continue to reflect
multiple levels of severity. Because the listings are the only basis on
which children qualify for benefits, the lack of a uniform severity
level in the listings raises equity concerns.
--------------------------- Indexing Terms -----------------------------
REPORTNUM: HEHS-99-103
TITLE: Supplemental Security Income: Progress Made in
Implementing Welfare Reform Changes; More Action Needed
DATE: 06/28/1999
SUBJECT: Disability benefits
Eligibility determinations
Children with disabilities
Social security benefits
Income maintenance programs
Eligibility criteria
Administrative law
IDENTIFIER: SSI
Supplemental Security Income Program
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United States General Accounting Office GAO Report
to the Committee on Finance, U.S. Senate, and the Committee on
Ways and Means, House of Representatives June 1999
SUPPLEMENTAL SECURITY INCOME Progress Made in Implementing Welfare
Reform Changes; More Action Needed GAO/HEHS-99-103 GAO United
States General Accounting Office Washington, D.C. 20548 Health,
Education, and Human Services Division B-278984 June 28, 1999 The
Honorable William V. Roth, Jr. Chairman The Honorable Daniel
Patrick Moynihan Ranking Minority Member Committee on Finance
United States Senate The Honorable Bill Archer Chairman The
Honorable Charles B. Rangel Ranking Minority Member Committee on
Ways and Means House of Representatives The early and mid-1990s
was a period of unprecedented growth in the Supplemental Security
Income (SSI) disability program for children. The program provides
monthly cash payments for blind or disabled children who meet the
program's income and resource requirements. These payments may be
used for any purpose that benefits the child, including provision
of food, clothing, and shelter, as well as disability-related
services.1 From the end of 1989 through 1996, the number of
children receiving SSI benefits more than tripled, from 265,000 to
955,000.2 Concerned about this rapid growth and allegations of
program abuse, the Congress made changes to tighten children's
eligibility for the SSI program through the Personal
Responsibility and Work Opportunity Reconciliation Act (P.L. 104-
193), commonly referred to as welfare reform, enacted in August
1996. The Congress made these changes to the SSI program to ensure
that only needy children with severe disabilities receive
benefits.3 Specifically, the welfare reform act made the
eligibility criteria for disabled children more restrictive and
added provisions to ensure that 1In most cases, a disabled child's
SSI benefit is paid on behalf of the child to a representative
payee, such as a parent or relative. The representative payee is
responsible for determining the child's needs-defined as the
immediate and reasonably foreseeable essentials for living-and
using the payments only for the child's use and benefit.
Representative payees must submit written reports accounting for
the use of the benefit when requested by SSA to do so. 2The SSI
program also provides monthly benefits to low-income adults who
are aged, blind, or disabled. From the end of 1989 through 1996,
the number of blind or disabled adults aged 18 to 64 receiving SSI
increased 55 percent, from 2.3 to 3.6 million. 3The Congress, in
its conference report on the welfare reform legislation, did not
precisely define the term "severe disabilities." The conference
report noted that the conferees use the term "severe" in its
"common sense meaning." Page 1
GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984 only
children who meet the more restrictive criteria continue to
receive benefits. It also required the Social Security
Administration (SSA) to issue regulations to implement these
changes.4 The new law defined disability in children as a
medically determinable physical or mental impairment that "results
in marked and severe functional limitations." Under this
definition, SSA's listing of impairments, which describe medical
criteria for common physical and mental impairments that are
considered so severe as to be disabling, are now the only basis on
which children qualify for benefits.5 The law required SSA to make
a one-time redetermination of the eligibility of children already
on the rolls who may not meet the new eligibility criteria.
Further, the law required SSA, on an ongoing basis, to conduct
continuing disability reviews (CDR) of (1) low-birth-weight
babies, (2) all other children under age 18 whose impairments are
likely to improve, and (3) 18-year-olds.6 The law also required
the child's representative payee, at the time of each CDR, to
document that the child is and has been receiving medically
necessary and available treatment for his or her impairment.7 SSA
administers the SSI program with assistance from state agencies
known as disability determination services (DDS), which make
initial and continuing eligibility determinations on behalf of
SSA. This report continues our effort to monitor SSA's progress in
implementing these key provisions, in response to the law's
mandate that GAO report to 4In light of the congressional mandate
to issue regulations needed to carry out the new statutory
provisions as expeditiously as possible, SSA, in accordance with
the Administrative Procedure Act, issued interim final regulations
in February 1997 with a request for public comments. These
regulations went into effect on April 14, 1997. 5Prior to welfare
reform, a child whose impairment was not severe enough to qualify
under SSA's medical listings could still be found eligible for
benefits if his or her impairment substantially limited his or her
ability to function in an age-appropriate manner. 6The law
distinguishes between CDRs, required for low-birth-weight babies
and other children whose impairments are likely to improve, and
redeterminations required for 18-year-olds. Benefits generally
cannot be terminated as a result of a CDR unless the recipient's
impairment has improved. However, benefits to 18-year-olds can be
terminated if they do not meet the disability criteria for adults,
regardless of whether their medical condition has improved.
Because SSA considers the redeterminations of 18-year-olds as part
of its CDR workload, this report refers to the reviews of 18-year-
olds as CDRs. 7The treatment requirement does not apply to 18-
year-olds. Although not addressed in this report, the law also
included provisions that (1) restricted the purposes for which
large retroactive SSI benefit payments to children can be used and
(2) reduced the monthly SSI benefit to children in institutions
whose care is paid for by private health insurance. Page 2
GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984 the
Congress on the impact of these changes on the SSI program.8
Specifically, this report describes SSA's progress in (1)
redetermining the eligibility of children already receiving
benefits against the law's new eligibility criteria, (2)
implementing the law's requirements for ongoing CDRs and the
related treatment provision, and (3) revising the interim final
regulations to implement the law's eligibility criteria and the
medical listings for childhood impairments, which are used to
determine whether a child is disabled. To address these questions,
we interviewed SSA headquarters' officials responsible for
implementing the law's key provisions; reviewed childhood
disability program policies, procedures, and records; and
submitted written questions to SSA officials concerning the new
treatment provisions and the status of revisions to the final
implementing regulations and the medical listings for childhood
impairments. We also discussed with SSA and Congressional Budget
Office officials the estimated number of children affected by
changes in the program's eligibility criteria. We performed this
assignment between August 1998 and April 1999 in accordance with
generally accepted government auditing standards. Results in Brief
SSA has completed 98 percent of the one-time eligibility
redeterminations required for 288,000 children already receiving
benefits when welfare reform was enacted. By November 1998, these
redeterminations had found about 115,300 children (or about 42
percent of the 273,600 children whose medical status was
reexamined) to be ineligible for SSI.9 However, the actual number
of children who ultimately will lose benefits is not yet known,
because about half of the 115,300 children found ineligible have
appealed the results of their redeterminations. SSA currently
estimates that about 100,000 children (about 10 percent of
children receiving SSI benefits at the end of 1996) will be found
ineligible for SSI after all required redeterminations and appeals
are completed. In fiscal year 1997, SSA conducted CDRs, when
required, on two of the three groups of children targeted by the
new law: low-birth-weight babies (7,100) and 18-year-olds
(48,800). However, SSA did not conduct CDRs in 1997 for the
largest of the three groups-all other children under 18 whose
8Supplemental Security Income: SSA Needs a Uniform Standard for
Assessing Childhood Disability (GAO/HEHS-98-123, May 6, 1998, and
GAO/T-HEHS-98-206, July 7, 1998); and Supplemental Security
Income: Review of SSA Regulations Governing Children's Eligibility
for the Program (GAO/HEHS-97-220R, Sept. 16, 1997). 9This is the
most recent period for which data are available. SSI benefits were
terminated for an additional 9,900 children for nonmedical
reasons, such as not meeting the program's financial eligibility
requirements. Page 3 GAO/HEHS-
99-103 SSI: Progress Made; Action Needed B-278984 impairments are
likely to improve. Existing backlogs and competing workloads have
impeded SSA's ability to perform CDRs on this group. When fiscal
year 1998 began, SSA had 371,000 CDRs to complete for these
children. SSA plans to ensure that all required childhood CDRs
will be completed or underway by 2000. The delay in conducting
most CDRs also delayed application of the law's new requirement
that the child's representative payee provide evidence, at the
time of each CDR, that the child is and has been receiving
medically necessary and available treatment for his or her
impairment. SSA has just begun collecting information from DDSs
documenting whether children have been receiving treatment. SSA
has not yet decided whether any revisions are necessary to the
interim final regulations that were issued to implement the law's
new definition of disability for children. SSA has taken initial
steps to update its medical listing of impairments, which are used
to determine whether a child qualifies for benefits. However, it
has not revised its medical listings to ensure that all children
are assessed against a uniform severity standard. While SSA says
it has made updating the listings a priority and that it plans to
eliminate inconsistencies among the listings as it proceeds, it
has not set a timetable for achieving this. Until SSA completes
this initiative, its medical listings for childhood impairments
will continue to reflect multiple levels of severity and therefore
will not ensure equity among children receiving SSI disability
benefits. Background The welfare reform law made the
eligibility criteria for children more restrictive and applied the
new criteria to children already receiving benefits as well as to
new applicants. The new law (1) redefined disability from an
impairment comparable to one that would prevent an adult from
working to one that results in "marked and severe functional
limitations"; (2) eliminated the individualized functional
assessment (IFA), which had been used to award benefits to
children whose impairments were not severe enough to qualify under
SSA's medical listings; and (3) removed maladaptive behavior as a
discrete criterion for assessing a child's personal and behavioral
functioning. The law required SSA to make a one-time
redetermination of the eligibility of child recipients who had
been found eligible on the basis of the IFA or maladaptive
behavior. To implement the new law, SSA issued interim final
regulations in February 1997 that defined an impairment that
results in "marked and severe functional limitations" as one that
meets, medically equals, or functionally equals one of SSA's
medical listings. The medical listings are Page 4
GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984
regulations describing medical signs, symptoms, and laboratory
findings for a list of common physical and mental impairments that
are so severe that disability can be presumed for anyone who is
not working and who has an impairment that meets the criteria of
the listing. Since the listings cannot include every possible
impairment or combination of impairments a person can have, SSA's
rules also provide that an impairment or combination of
impairments can medically or functionally equal the severity of a
listing.10 For a child to be determined eligible for benefits
under this new and stricter standard of severity, his or her
impairment must generally result in marked functional limitations
in two areas of functioning, such as social and motor, or an
extreme limitation in one area.11 SSA has identified 28 listings,
however, as ones most likely to allow children with less than two
marked or one extreme functional limitation to be found eligible
for benefits. The law also added requirements for SSA to regularly
review the continuing eligibility of children receiving SSI. It
required SSA to perform CDRs (1) during the first year after birth
for low-birth-weight babies and (2) at least once every 3 years
for other children under 18 whose conditions are considered likely
to improve.12 At the time of these reviews, the child's
representative payee must present evidence demonstrating that the
child is and has been receiving medically necessary and available
treatment for his or her impairment.13 If the representative payee
cannot provide SSA with an acceptable reason for not complying
with this provision, and SSA decides that it is in the child's
best interest, SSA may pay the child's SSI benefits to another
representative payee.14 The law also required SSA to 10There are
separate listings for adults and children. The childhood listings
are used first in evaluating childhood claims. If the child's
impairment does not meet or equal the severity of a childhood
listing, use of the adult listings may be considered. 11Areas of
functioning are assessed on the basis of children's ages. Social,
cognition/communication, and motor areas are assessed for children
of all ages; responsiveness to stimuli is assessed in children
under age 1; and personal functioning and the ability to
concentrate, persist at tasks at hand, or keep pace are assessed
for children aged 3 and older. 12The law also specified that SSA
could, at its option, review children who are unlikely to improve.
In addition, the Balanced Budget Act of 1997 (P.L. 105-33)
modified the welfare reform law, so that a CDR may be scheduled on
a low-birth-weight baby after the baby's first birthday if the
baby is not expected to improve within the first 12 months after
birth. 13The payee need not show proof of treatment if SSA decides
that the disabling impairment is not amenable to treatment.
14Acceptable reasons include that the treatment is (1) contrary to
established teachings or tenets of the child's religion; (2) very
risky, such as open-heart surgery or an organ transplant; or (3)
involves amputation of an extremity or a major part of an
extremity. Page 5 GAO/HEHS-
99-103 SSI: Progress Made; Action Needed B-278984 redetermine the
eligibility of children, after they reach age 18, against the
adult criteria for disability.15 SSA administers the SSI program
with the help of state DDSs. DDSs make disability determinations
and eligibility redeterminations, assess recipients' potential for
medical improvement, and schedule and conduct CDRs. Adverse
eligibility determinations are subject to appeal. Claimants
initially determined by the DDS to be ineligible for benefits have
60 days to request the DDS to reconsider their cases. If they
continue to receive an unfavorable result, they can appeal to an
SSA administrative law judge, SSA's Appeals Council, and finally
to federal court. It can take 2 years or more for cases to work
their way through all levels of appeals. Most One-Time
By November 1998, SSA had completed 98 percent of the 288,000 one-
time Redeterminations redeterminations required for
children who had been awarded benefits on the basis of the IFA or
because of maladaptive behavior. Of the 273,600 Completed, But
Final children whose medical status was redetermined, about
115,300 (about Outcomes Await 42 percent) were found no
longer eligible for SSI benefits.16 However, the actual number of
children who ultimately will lose benefits is unknown, Appeal
because about 55,200 of the 115,300 children found ineligible have
appealed the results of their redeterminations. SSA currently
estimates that about 100,000 children will be found ineligible for
SSI after all required redeterminations and appeals are complete.
This estimate is much lower than SSA's and the Congressional
Budget Office's original estimates that 185,000 and 190,000
children, respectively, would be found ineligible for benefits as
a result of these redeterminations. However, those estimates were
made when the welfare reform legislation was enacted and reliable
historical data were not available to project the number of
children for whom redeterminations were required and the number of
children who would still qualify for benefits under the new law.
SSA's new estimate considers the effect of the new regulations and
the actions taken by SSA in response to its experience in
implementing the regulations. When the interim regulations were
issued in February 1997, SSA refined its initial estimate and
projected that 135,000 children would 15The welfare reform law
repealed the requirement that SSA conduct CDRs on one-third of SSI
recipients attaining age 18 in each of fiscal years 1996, 1997,
and 1998. 16SSI benefits were terminated for nonmedical reasons,
such as not meeting the program's financial eligibility
requirements, for an additional 9,900 children. Page 6
GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984 not
qualify for benefits under the regulations. Subsequently, because
of problems SSA identified during a "top-to-bottom" review of how
the new interim regulations were being implemented, SSA decided to
re-review the claims of about 36,000 children who had been found
no longer eligible as a result of the redeterminations.17 By
November 1998, SSA had re-reviewed about 21,800 of these children,
reversing the decision to terminate benefits for about 5,000 of
them. In addition, SSA granted about 63,300 children who had been
found ineligible another opportunity to appeal, and about 26,900
children took advantage of this opportunity. SSA Is Making
SSA has been able to conduct CDRs when required on two of the
three Progress in groups of children
targeted by the new law: low-birth-weight babies and 18-year-olds.
However, SSA did not conduct CDRs on the largest of the three
Implementing Some groups-all other children under
18 whose impairments are likely to CDR Requirements;
improve. The delay in conducting these CDRs has delayed
application of the new law's requirement that a child's
representative payee document, at the Others Delayed
time of each CDR, that the child is or has been receiving
medically necessary and available treatment for his or her
impairment. Low-birth-weight babies and children turning age 18
constitute a rather small portion of all children receiving SSI
benefits, and SSA has been able to stay current in processing the
required CDRs for these two groups. In fiscal year 1997, DDSs
completed CDRs on approximately 7,100 low-birth-weight babies and
48,800 18-year-olds for whom CDRs were required. Initial DDS
determinations found over one-third of low-birth-weight babies and
over one-half of 18-year-olds to be no longer eligible for
benefits (see table 1).18 Table 1: CDRs Completed During Fiscal
Year 1997
Number Percentage Total CDR determined
determined Recipient group determinations
ineligible ineligible Low-birth-weight babies
7,091 2,604 37 Children
who attain age 18 48,834
26,399 54 Note: Data represent initial
CDR determinations. Source: SSA. 17SSA, Social Security: Review of
SSA's Implementation of the New SSI Childhood Disability
Legislation (Baltimore, MD: 1997). 18During fiscal year 1998, SSA
scheduled CDRs for all of the approximately 12,400 low-birth-
weight babies and 67,000 18-year-olds for whom CDRs were required.
The outcomes of these CDRs were not available at the time we did
our work. Page 7 GAO/HEHS-99-
103 SSI: Progress Made; Action Needed B-278984 According to SSA,
CDRs conducted on low-birth-weight babies in prior fiscal years
have also found many to be ineligible. SSA found that, as these
babies grow older and gain weight, their impairments often improve
to the extent that they are no longer disabled. In addition, the
number and proportion of 18-year-olds determined ineligible could
change in future years as SSA conducts more CDRs of children under
age 18 and removes, at an earlier age, those no longer disabled.
Although SSA has not conducted all of the required CDRs for
children under 18 whose conditions are likely to improve, it has
developed a plan to become current in conducting all required
childhood CDRs by 2000. When fiscal year 1998 began, SSA had a
caseload of 371,000 CDRs to be completed for these children. This
caseload developed because few CDRs had been done in the past and,
in fiscal year 1997, SSA diverted DDS staff from conducting these
CDRs in order to process the one-time redeterminations of child
recipients.19 Having now completed most of these redeterminations,
SSA expects to make progress in completing the required childhood
CDRs and plans to ensure that all required childhood CDRs will be
completed or underway by fiscal year 2000. It also plans to stay
up-to-date thereafter with all childhood CDRs coming due. The
delay in conducting most of the required CDRs on children under
age 18 has also delayed application of welfare reform's new
treatment provision. Although SSA has issued implementing
regulations and instructions and notified representative payees of
the new treatment provision, the agency has just begun collecting
management information needed to track implementation of this new
requirement. In January 1999, SSA issued instructions to DDS
adjudicators requiring them to document the results obtained from
applying the treatment requirement. SSA stated that it does not
expect to have meaningful management information in the immediate
future to document the effect of the law's treatment requirement
on children, because this provision is applied when CDRs are
conducted, and SSA has only recently begun conducting CDRs in
large numbers. 19The welfare reform law required SSA to complete
the one-time redeterminations within 1 year of enactment. The
Balanced Budget Act of 1997 extended the time frame for completing
the redeterminations to 18 months or as soon as practicable
thereafter. Page 8 GAO/HEHS-99-
103 SSI: Progress Made; Action Needed B-278984 Revisions to
SSA requested and received public comments on its interim final
Regulations Still regulations, issued in February 1997, to
implement the law's new definition of disability for children. The
agency has not issued revised final Pending; Multiple
regulations in response to these public comments, and it does not
expect Eligibility Standards to do so for some time. SSA states
that it is still studying and analyzing the results of its
experience in implementing the interim final regulations. SSA
Remain has initiated several research studies
(and expects to conduct several more over the next few years) to
determine how to refine its procedures and regulations for
adjudicating children's disability claims. SSA stated that it
would be premature to issue revised final regulations before its
analysis and research are complete. In the meantime, SSA is still
operating under the interim final regulations. Under SSA's interim
final regulations, meeting, medically equaling, or functionally
equaling the medical listings is the only basis on which children
can be found eligible for benefits. However, SSA has not updated
most of its childhood medical listings for many years; therefore
some listings do not reflect the latest advances in medicine and
science, including advances in medical knowledge, methods of
evaluating impairments, and treatment.20 In addition, our May 1998
report on SSA's efforts to assess childhood disability pointed out
that SSA's medical listings do not reflect a uniform level of
severity-that is, not all listings require the same degree of
functional limitation for the child to be found eligible for
benefits. In defining an impairment that results in "marked and
severe functional limitations" as one that meets, medically
equals, or functionally equals one of SSA's medical listings,
SSA's interim final regulations state that the child's impairment
must generally result in marked functional limitations in two
areas of functioning, such as social and motor development, or an
extreme limitation in one area of functioning. SSA established the
"two marked or one extreme" general rule from the severity
criteria cited in the agency's mental disorders listings. However,
not all listings are set at a level of severity equivalent to two
marked functional limitations or one extreme functional
limitation. 20Since 1990, SSA has updated its childhood medical
listings for mental disorders, cardiovascular disorders, and
respiratory disorders. Almost two-thirds of the children receiving
benefits in December 1998 had mental, cardiovascular, or
respiratory disorders. It also developed new listings for immune
disorders and made several other revisions to its medical
listings. However, the listings for neurological system, digestive
system, endocrine system, and hemic and lymphatic system, special
senses and speech, and growth impairment disorders have not been
updated since 1977; and the listings for genito-urinary system and
musculoskeletal system disorders have not been updated since 1985.
Page 9 GAO/HEHS-99-103 SSI:
Progress Made; Action Needed B-278984 Although the welfare reform
law defines disability in terms of functional limitations, many of
the listings do not specify functional limitations at all; their
severity criteria are expressed in terms of laboratory values,
such as test results, or other signs and symptoms. Other listings
include functional criteria as part of the criteria for assessing
the impairment's severity, but do not clearly define the degree of
functional limitation required for a child to be found eligible
for benefits. For example, some listings describe functional
limitations as "persistent" or "significant," which are not
defined in relation to the terms "marked" or "extreme."
Nonetheless, SSA has identified 28 listings as ones that are most
likely to enable children whose impairments result in fewer than
two marked functional limitations or one extreme functional
limitation to be found eligible for benefits.21 Twenty-one of
these listings have not been updated since 1977. According to SSA,
many more listings may allow some children whose impairments are
below the "two marked or one extreme" threshold to be found
eligible for benefits. Because the medical listings are now the
only basis on which children can be found eligible for benefits,
the lack of uniform severity criteria in the medical listings
raises equity concerns. Consequently, our May 1998 report
recommended that SSA act immediately to revise its medical
listings to incorporate advances in medicine and science and to
reflect a uniform standard of severity. SSA has taken initial
steps to update its medical listings for childhood impairments.
SSA has stated that updating the medical listings for childhood
impairments is a priority, and that it has begun to recruit
additional staff and has increased its research budget
specifically for this purpose.22 Although SSA has not set a
completion date for revising the listings, in general, it plans to
review the listings sequentially by body system, undertaking the
"short-term fixes" first and eliminating inconsistencies among
listings as it completes its review of each body system.23 In
addition to conducting research, SSA plans to consult with medical
experts and seek public involvement as part of this effort.
21Children can meet or medically equal these listings if their
impairments are more severe than these listings require.
Therefore, some of the children who meet or medically equal these
listings may have impairments that result in two marked functional
limitations or one extreme functional limitation. However, SSA
cannot identify the number of children who have been awarded
benefits based on the 28 listings or how many of these children
have impairments at the two marked or one extreme severity level.
22SSA will also be updating the medical listings for adult
impairments as part of this effort. 23SSA's medical listing of
impairments are grouped into categories known as body systems. The
listings for childhood impairments are divided into 14 such body
systems, including the musculoskeletal, respiratory,
cardiovascular, and endocrine systems; special senses and speech;
and mental disorders. Page 10
GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984 SSA
told us that the current childhood listings are appropriate for
identifying disabled children, and that it will ensure that the
updated listings reflect impairments that result in marked and
severe functional limitations, as required by the welfare reform
law. Further, in observing that some listings contain only medical
criteria and others include functional criteria, SSA questioned
whether it is always possible to directly compare the severity of
listings to each other. Moreover, SSA said that the "two marked or
one extreme" rule is not appropriate in all cases. SSA explained
that there are some listings for physical impairments, such as
cancer, for which medical criteria alone are sufficient for
determining that a child is disabled. As long as SSA ensures that
all listings result in marked and severe functional limitations,
it maintains that the listings will be uniform in severity to the
extent feasible. Conclusion SSA has made significant
progress in implementing welfare reform's requirements for
assessing children's continuing eligibility for benefits.
Specifically, it has completed almost all of the one-time
redeterminations required for children who had been receiving
benefits when welfare reform was enacted, and it has conducted
CDRs when required on low-birth-weight babies and 18-year-olds.
Further, it has a plan to ensure that all required CDRs for
children under 18 whose conditions are likely to improve will be
completed or underway by 2000. However, SSA has not yet decided
whether any revisions are necessary to the interim final
regulations that were issued to implement the law's new definition
of disability for children, and it has made little progress in
updating its medical listings for childhood impairments. Although
it has taken initial steps to accomplish the update, such as
recruiting staff, it has not set a timetable for completing this
task. Until SSA completes this initiative, its medical listings
for childhood impairments will continue to reflect multiple levels
of severity. Because the listings are the only basis on which
children qualify for benefits, the lack of a uniform severity
level in the listings raises equity concerns. Accordingly, the
recommendation we made in our May 1998 report still has merit.
Specifically, we believe that the SSA Commissioner should promptly
set a timetable for updating the medical listings for childhood
impairments and that the updated listings be set, to the extent
possible, at a uniform level of severity in order to ensure equity
among children receiving SSI disability benefits. Agency Comments
We provided a draft of this report to SSA for review and comment.
SSA's and Our Response comments concerned our discussion of the
need for SSA to revise its Page 11
GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984 medical
listings for children. We revised our report to recognize that,
since 1990, SSA has updated the childhood medical listings for
mental, cardiovascular, and respiratory disorders and that most
children receiving benefits have these disorders. We also revised
our report to reflect SSA's comment that advances in treatment
alone may not determine whether listings need to be updated.
Nevertheless, because meeting or medically or functionally
equaling the listings is the only basis on which children qualify
for benefits, we believe SSA needs to continually review its
listings to ensure that they reflect the latest advances in
medical knowledge, methods of evaluating impairments, and
treatment. Finally, we revised our report to clarify that SSA
identified 28 listings as the ones that are most likely to allow
children with less than two marked functional limitations or one
extreme functional limitation to qualify for benefits. SSA stated
that relatively few children were awarded benefits based on the 28
listings, and it believes that most children who meet the
requirements of these listings would have marked limitations in
two areas of functioning or an extreme limitation in one area. We
revised our report to recognize that some children who qualify for
benefits under these listings may have functional limitations at
the "two marked or one extreme" level. However, SSA cannot
identify the number of children who have been awarded benefits
based on the 28 listings, or the number of these children who
function at the "two marked or one extreme" level. SSA also
provided technical comments, which we incorporated where
appropriate. SSA's comment letter and page one of its comments are
included in appendix I. (SSA's technical comments are not
included.) We are providing copies of this report to the Honorable
Kenneth S. Apfel, Commissioner of Social Security, and other
congressional committees with an interest in this matter. We will
also make copies available to others upon request. Page 12
GAO/HEHS-99-103 SSI: Progress Made; Action Needed B-278984 Please
contact me or Carol Dawn Petersen on (202) 512-7215 if you have
any questions about this report. Other major contributors were
Ellen Habenicht, William Hutchinson, Daniel Schwimer, and Gretta
L. Goodwin. Cynthia M. Fagnoni Director, Education, Workforce, and
Income Security Issues Page 13 GAO/HEHS-
99-103 SSI: Progress Made; Action Needed Contents Letter
1 Appendix I
16 Comments From the Social Security Administration Related GAO
Products
20 Table Table 1: CDRs Completed During Fiscal
Year 1997 7 Abbreviations CDR
continuing disability review DDS disability determination
service IFA individualized functional assessment SSA
Social Security Administration SSI Supplemental Security
Income Page 14 GAO/HEHS-99-103 SSI:
Progress Made; Action Needed Page 15 GAO/HEHS-99-103 SSI:
Progress Made; Action Needed Appendix I Comments From the Social
Security Administration Page 16 GAO/HEHS-99-103 SSI: Progress
Made; Action Needed Appendix I Comments From the Social Security
Administration Page 17 GAO/HEHS-99-
103 SSI: Progress Made; Action Needed Page 18 GAO/HEHS-99-103
SSI: Progress Made; Action Needed Page 19 GAO/HEHS-99-103
SSI: Progress Made; Action Needed Related GAO Products
Supplemental Security Income: SSA Needs a Uniform Standard for
Assessing Childhood Disability (GAO/HEHS-98-123, May 6, 1998, and
GAO/T-HEHS-98-206, July 7, 1998). SSA's Management Challenges:
Strong Leadership Needed to Turn Plans Into Timely, Meaningful
Action (GAO/T-HEHS-98-113, Mar. 12, 1998). Supplemental Security
Income: Review of SSA Regulations Governing Children's Eligibility
for the Program (GAO/HEHS-97-220R, Sept. 16, 1997). Children
Receiving SSI by State (GAO/HEHS-96-144R, May 15, 1996). SSA
Initiatives to Identify Coaching (GAO/HEHS-96-96R, Mar. 5, 1996).
Supplemental Security Income: Growth and Changes in Recipient
Population Call for Reexamining Program (GAO/HEHS-95-137, July 7,
1995). Social Security: New Functional Assessments for Children
Raise Eligibility Questions (GAO/HEHS-95-66, Mar. 10, 1995).
Social Security: Federal Disability Programs Face Major Issues
(GAO/T-HEHS-95-97, Mar. 2, 1995). Supplemental Security Income:
Recent Growth in the Rolls Raises Fundamental Program Concerns
(GAO/T-HEHS-95-67, Jan. 27, 1995). Social Security: Rapid Rise in
Children on SSI Disability Rolls Follows New Regulations
(GAO/HEHS-94-225, Sept. 9, 1994). (207026) Page 20
GAO/HEHS-99-103 SSI: Progress Made; Action Needed Ordering
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