Supplemental Security Income: SSA Needs a Uniform Standard for Assessing
Childhood Disability (Statement/Record, 07/07/1998, GAO/T-HEHS-98-206).
The Social Security Administration (SSA) has made considerable progress
in implementing the new eligibility criteria mandated by welfare reform
for childhood disability benefits under the Supplemental Security Income
program. SSA has taken important steps to ensure fairness by identifying
children whose benefits may have been terminated inappropriately and
taking remedial action to rereview their cases. However, because SSA's
medical listings reflect multiple levels of severity, it also needs to
expedite updating and modifying its medical listings to guarantee that
all children are assessed against a uniform severity standard. The need
to revise the listings is a long-standing problem that GAO reported
three years ago. Moreover, SSA needs to follow through on its plan to
monitor and continually improve the quality of decisions regarding
children.
--------------------------- Indexing Terms -----------------------------
REPORTNUM: T-HEHS-98-206
TITLE: Supplemental Security Income: SSA Needs a Uniform Standard
for Assessing Childhood Disability
DATE: 07/07/1998
SUBJECT: Children with disabilities
Eligibility criteria
Social security benefits
Disability benefits
Income maintenance programs
Mental illnesses
IDENTIFIER: Supplemental Security Income Program
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GAO/T-HEHS-98-206
Cover
================================================================ COVER
Before the Subcommittee on Social Security and Family Policy,
Committee on Finance, U.S. Senate
For Release on Delivery
Expected at 2:00 p.m.
Tuesday, July 7, 1998
SUPPLEMENTAL SECURITY INCOME - SSA
NEEDS A UNIFORM STANDARD FOR
ASSESSING CHILDHOOD DISABILITY
Statement for the Record by Cynthia M. Fagnoni,
Director, Income Security Issues
Health, Education, and Human Services Division
GAO/T-HEHS-98-206
GAO/HEHS-98-206T
(207041)
Abbreviations
=============================================================== ABBREV
CBO - Congressional Budget Office
IFA - individualized functional assessment
SSA - Social Security Administration
SSI - Supplemental Security Income
SUPPLEMENTAL SECURITY INCOME: SSA
NEEDS A UNIFORM STANDARD FOR
ASSESSING CHILDHOOD DISABILITY
============================================================ Chapter 0
Mr. Chairman and Members of the Subcommittee:
I am pleased to provide this statement for the record in which we
discuss the Social Security Administration's (SSA) implementation of
the new eligibility criteria for childhood disability benefits under
the Supplemental Security Income (SSI) program. In 1997, almost
900,000 children younger than 18 received about $5 billion in SSI
benefits. The Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (P.L. 104-193), commonly referred to as
welfare reform, made eligibility for childhood SSI benefits more
restrictive.\1 In February 1997, the Social Security Administration
(SSA) published regulations to implement the new definition of
disability for the SSI children's program set forth in the welfare
reform law. Under the more restrictive standard, a child's
impairment generally must result in marked limitations in two areas
of functioning or an extreme limitation in one area. Previously, a
child could be found eligible if his or her impairment resulted in
one marked and one moderate limitation or three moderate limitations.
In September 1997, we reported that SSA's regulations establishing a
new severity standard are consistent with the law and are well
supported.\2 Since then, we have been monitoring SSA's adjudication
of cases under the new regulations for 288,000 children whose
eligibility was subject to review against the new standard as well as
for about 370,000 new applicants. In May 1998, we reported to the
Chairman of the Subcommittee on Human Resources, House Ways and Means
Committee, our early findings regarding SSA's implementation of the
new standard.\3 This statement summarizes and updates the report's
findings. (See the list of related products on children receiving
SSI disability benefits at the end of this statement.)
In summary, SSA has made considerable progress in implementing the
welfare reform changes in eligibility for SSI children. It has taken
important steps to safeguard fairness by identifying children whose
benefits may have been terminated inappropriately and establishing
remedial action to rereview their cases. However, because SSA's
medical listings reflect multiple levels of severity, SSA also needs
to expedite updating and modifying its medical listings to ensure
that all children are assessed against a uniform severity standard.
The need to revise the listings is a long-standing problem that we
reported 3 years ago. Moreover, SSA needs to take concerted action
to follow through on its plan for monitoring and continually
improving the quality of decisions regarding children. Consistent
with our legislative mandate, we will continue to focus our work on
SSA's efforts to provide reasonable assurance that it can administer
the program consistently and improve the accuracy of childhood
disability decisions.
--------------------
\1 Sec. 232 of P.L. 104-193 mandates that we report to the Congress
by January 1, 1999, on (1) the effect of the legislative changes on
the SSI program and (2) the extra expenses incurred by families of
children receiving SSI which are not covered by other public
programs. This statement is based on our work to date under the
first mandated study.
\2 Supplemental Security Income: Review of SSA Regulations Governing
Children's Eligibility for the Program (GAO/HEHS-97-220R, Sept. 16,
1997).
\3 Supplemental Security Income: SSA Needs a Uniform Standard for
Assessing Childhood Disability (GAO/HEHS-98-123, May 6, 1998).
BACKGROUND
---------------------------------------------------------- Chapter 0:1
The Congress made the eligibility criteria for children to receive
SSI more restrictive in order to help ensure that only needy children
with severe disabilities are eligible for benefits. From the end of
1989 through 1996, the number of children younger than 18 receiving
SSI had more than tripled, from 265,000 to 955,000. This growth
occurred after SSA initiated outreach efforts and issued two sets of
regulations that made the eligibility criteria for children less
restrictive, particularly for children with mental impairments.\4
One regulatory change, issued in December 1990, revised and expanded
SSA's medical listings for childhood mental impairments by adding
such impairments as attention deficit hyperactivity disorder and
incorporating functional criteria into the listings. Examples of
such functional criteria include standards for assessing a child's
social skills; cognition and communication skills; and the ability to
concentrate, keep pace, and persist at tasks at hand. The medical
listings are regulations containing examples of medical conditions,
including both physical and mental impairments, that are so severe
that disability can be presumed for anyone who is not performing
substantial gainful activity and who has an impairment that "meets"
the criteria--medical signs and symptoms and laboratory findings--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 "equal" or be "equivalent to" the severity of a listing. There
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, the adult listings are considered.
The second regulatory change, issued in February 1991 in response to
the Sullivan v. Zebley Supreme Court decision, added two new bases
for finding children eligible for benefits, both of which required an
assessment of a child's ability to function: functional equivalence,
which was set at "listing level" severity, and an individualized
functional assessment (IFA), which was set at a lower threshold of
severity.
Functional equivalence is based on the principle that it is the
functional limitations resulting from an impairment that make the
child disabled, regardless of the particular medical cause. It was
added as a basis for eligibility in response to the Supreme Court's
determination in the Zebley case that SSA's medical listing of
impairments--which had been the only basis for eligibility--was
incomplete. Under functional equivalence, a child could be found
eligible for benefits if the child's impairment limited his or her
functional ability to the same degree as described in a listed
impairment. Functional equivalence is particularly appropriate for
assessing children with combinations of physical and mental
impairments.
The IFA allowed children whose impairments were less severe than
listing level to be found eligible if their impairments were severe
enough to substantially limit their ability to act and behave in
age-appropriate ways. A child was generally found eligible under the
IFA if his or her impairment resulted in moderate functional
limitations in three areas of functioning or a marked limitation in
one area and a moderate limitation in another area.\5
In 1995, we reported that the subjectivity of the IFA called into
question SSA's ability to ensure reasonable consistency in
administering the SSI program, particularly for children with
behavioral and learning disorders. We suggested that the Congress
consider eliminating the IFA and directing SSA to revise its medical
listings.\6
--------------------
\4 Social Security: Rapid Rise in Children on SSI Disability Rolls
Follows New Regulations (GAO/HEHS-94-225, Sept. 9, 1994).
\5 Under the IFA, areas of functioning were assessed on the basis of
children's ages. Social, communication, cognition, and motor skills
were assessed for children of all ages. Responsiveness to stimuli
was assessed in children under age 1; personal and behavioral skills
were assessed for children aged 1 and older; the ability to
concentrate, persist at tasks at hand, and keep pace was assessed for
children aged 3 and older.
\6 Social Security: New Functional Assessments for Children Raise
Eligibility Questions (GAO/HEHS-95-66, Mar. 10, 1995.)
WELFARE REFORM RESTRICTS
CHILDHOOD ELIGIBILITY FOR SSI
BENEFITS
---------------------------------------------------------- Chapter 0:2
Several welfare reform provisions enacted in August 1996 made the
eligibility criteria for disabled children more restrictive: (1)
childhood disability was redefined from an impairment comparable to
one that would prevent an adult from working to an impairment that
results in "marked and severe functional limitations," (2) the IFA
was eliminated as a basis for determining eligibility for children,
and (3) maladaptive behavior was removed from consideration when
assessing a child's personal or behavioral functioning. Thus, such
behavior would be considered only once--in the assessment of that
child's social functioning--when determining whether the child had a
mental impairment severe enough to meet or equal the medical
listings. The law also required SSA to redetermine the eligibility
of children on the rolls who might not meet the new eligibility
criteria because they received benefits on the basis of the IFA or
maladaptive behavior.
FEWER CHILDREN ARE AFFECTED
BY THE LAW THAN WAS EARLIER
ESTIMATED
-------------------------------------------------------- Chapter 0:2.1
Earlier legislative proposals under consideration in 1995 might have
removed from the rolls as few as 45,000 to as many as 190,000
children, according to Congressional Budget Office (CBO) estimates.
After the welfare reform legislation was enacted in August 1996 but
before SSA issued its regulations, CBO estimated that about 170,000
children on the rolls would no longer be eligible for benefits.
After SSA issued its regulations in February 1997, CBO and SSA
estimates of children who would be removed from the rolls were very
close--131,000 and 135,000, respectively.
SSA identified 288,000 children as potentially affected by the
changes in the eligibility criteria because they had been awarded
benefits on the basis of the IFA or maladaptive behavior. Through
February 28, 1998, SSA reviewed the eligibility of 272,232 of the
288,000 children. Of these, 139,693 (51.3 percent) were found
eligible to continue to receive benefits and 132,539 (48.7 percent)
were found ineligible. Because the number of children deemed
ineligible does not yet reflect the results of all appeals, we do not
yet know the final outcome on all these cases. Children initially
deemed by a disability determination service to be ineligible have 60
days to request reconsideration of their case. If they continue to
receive an unfavorable result, they can appeal to an SSA
administrative law judge and, finally, to federal court. Recipients
can elect to continue receiving benefit payments during the appeal
process. Factoring in appeals and experience in conducting
redeterminations so far, SSA now estimates that 100,000 children will
be removed from the rolls as a result of the redeterminations.
SSA'S REVIEW IDENTIFIED
IMPLEMENTATION PROBLEMS AND
INITIATED CORRECTIVE ACTIONS
-------------------------------------------------------- Chapter 0:2.2
In December 1997, SSA issued a report on its "top-to-bottom" review
of the implementation of the new regulations to address concerns that
children may have had their benefits terminated unfairly.\7 SSA found
problems with the adjudication of claims for which mental retardation
was the primary impairment as well as potential procedural weaknesses
relating to notification of appeal rights and termination of benefits
for failure to cooperate with SSA requests for information needed to
redetermine eligibility.
To remedy these problems, SSA decided to rereview all children whose
benefits were terminated or denied on the basis of mental
retardation. SSA conducted training in March 1998 to clarify how
these claims should be adjudicated. Also, all cases terminated
because families did not cooperate with SSA in processing the claim,
such as by failing to provide requested medical information or to
take the child for a consultative examination, will be rereviewed.
SSA found that in two-thirds of these terminations, all the required
contacts had not been made or had not been documented in the file.
Finally, families of children whose benefits were terminated but did
not appeal are being given an additional 60-day period in which to
appeal their terminations. Notices of this right as well as the
right to continue to receive benefits while the appeal is pending
were sent out in February 1998.
--------------------
\7 For more information, see SSA, Social Security: Review of SSA's
Implementation of the New SSI Childhood Disability Legislation
(Baltimore, Md.: 1997).
REGULATIONS GENERALLY SET
SEVERITY AT TWO MARKED OR ONE
EXTREME LIMITATION
---------------------------------------------------------- Chapter 0:3
To implement the new law, SSA issued interim final regulations
establishing a new severity standard in February 1997, which we found
to be consistent with the law.\8
The regulations define an impairment that results in "marked and
severe functional limitations" as one that meets or medically or
functionally equals one of SSA's medical listings.\9 For a child to
be determined eligible for benefits under this new and stricter
standard of severity, the child's impairment must generally result in
marked functional limitations in two areas of functioning or an
extreme limitation in one area. SSA also eliminated the IFA and
removed the duplicate consideration of maladaptive behavior from the
mental disorders listings.
In developing its regulations, SSA concluded that the Congress meant
to establish a stricter standard of severity than "one marked, one
moderate" limitation, for several reasons. The Congress eliminated
the "comparable severity" standard of disability and the IFA, which
was created for evaluating impairments less severe than those in the
medical listings. A "one marked, one moderate" standard of severity
would have retained one of the standards under which children were
found eligible under the IFA, which SSA stated would violate the law.
Finally, SSA interpreted the conference report to mean that the
Congress intended the listings to be the last step in the disability
determination process for children.
--------------------
\8 In light of the congressional mandate to issue regulations needed
to carry out the new statutory provisions as expeditiously as
possible, SSA determined that there was good cause to waive the
notice of proposed rulemaking procedures. Instead, in accordance
with the Administrative Procedure Act, SSA issued interim final
regulations with a request for public comments. SSA stated that it
would issue revised rules if necessary.
\9 Previously, the IFA afforded children whose impairments were not
severe enough to meet or equal SSA's listings an additional basis on
which to qualify for benefits. The IFA, which was set at a lower
severity standard than the listings, was analogous to the test of
residual functional capacity for adults whose impairments are not of
listing level severity. Now, unlike adults, children can qualify
only under the listings.
SOME CHILDREN WITH LESS
SEVERE DISABILITIES STILL
RECEIVE BENEFITS
-------------------------------------------------------- Chapter 0:3.1
Although SSA articulated the "two marked or one extreme" severity
standard in its regulations, it did not modify its existing listings
to specifically incorporate functional criteria that would reflect
both the new definition of childhood disability and advances in
medicine and science. For example, because of advances in treatment,
some impairments no longer have as severe an effect on a child's
ability to function as they once did. As a result, some listings are
set below the "two marked or one extreme" threshold of severity, and
cases are being adjudicated at this less severe level as well as at
the "two marked or one extreme" severity level.
SSA has identified 28 listings that are most likely to enable
children whose impairments result in fewer than two marked functional
limitations or one extreme functional limitation to be awarded
benefits. Twenty-one of the 28 listings have not been revised since
March 1977. Our review shows that such less severe listings can
serve as the basis for awards even though SSA rejected the "one
marked, one moderate" level of severity in interpreting the "marked
and severe" functional limitations required by the welfare reform
law. Children who meet or medically equal these less severe listings
qualify for benefits under the regulations. At the same time, SSA
told us that the regulations prohibit the less severe listings from
being used to determine functional equivalence. In March 1997, SSA
stated that it planned to issue a Social Security ruling to clarify
that only listings at the "two marked or one extreme" level were to
be used in determining functional equivalence, but SSA has not yet
issued such a ruling. In the absence of such clarification, some
adjudicators may be using less severe listings in making functional
equivalence determinations. Reviewers in SSA's Office of Program and
Integrity Reviews have told us, however, that they would consider
this an error.
SSA has not identified how many children may have been awarded
benefits on the basis of these less severe listings. SSA told us
that unreliable coding of the listings used to determine eligibility
makes it difficult to quantify the extent of this problem. We do
know, however, that some of the listings below the "two marked or one
extreme" threshold are for prevalent impairments, including two of
six listings for the most common impairment--mental retardation--and
three listings for cerebral palsy, one for epilepsy, and one for
asthma. Other listings below the "two marked or one extreme"
threshold include one listing for juvenile rheumatoid arthritis, one
for juvenile diabetes, and two for diabetes insipidus. As of June
1998, SSA had not established a schedule for updating and modifying
its listings.
SSA IS TAKING STEPS TO IMPROVE
THE QUALITY OF DECISIONS ON
CHILDREN
---------------------------------------------------------- Chapter 0:4
SSA's quality assurance statistics on childhood cases show uneven
accuracy rates across the states. Although nationally the accuracy
rate for decisions on new childhood cases and redeterminations
exceeds SSA's standard of 90.6 percent, many states fall below the
standard. Specifically, for decisions made on new childhood cases
from June 1997 through February 1998, 5 states fell below the
90.6-percent accuracy standard for awards, and 9 states fell below
the standard for denials. For redeterminations, 10 states fell below
the standard for continuances, and 10 states fell below the standard
for cessations. Most of the errors have been in the documentation;
that is, there was some deficiency in the evidence that formed the
basis for the determination. In these cases, proper documentation of
the case could substantiate or reverse the decision.
Given the significant changes in adjudicating cases on the basis of
the new regulations, these statistics are not surprising. Moreover,
childhood cases historically have been among the more difficult cases
to adjudicate. We would expect SSA to be monitoring the decisions;
identifying areas of difficulty for adjudicators; and providing
additional clarification, guidance, and training to improve the
accuracy of decisions. In fact, this is exactly what SSA has been
doing, although its training schedule was delayed slightly.
Further, on February 18, 1998, SSA issued a memorandum detailing a
new quality review plan for childhood disability cases to ensure
correct and consistent application of the new regulations. The plan
includes special initiatives to ensure the quality of cases
readjudicated in response to the top-to-bottom review, as well as
initiatives to improve SSA's ongoing quality assurance reviews on
childhood cases. For the first time, SSA will be drawing separate
samples of new childhood claims and continuing disability reviews.
This should allow SSA to provide more timely feedback and policy
clarifications on the problems unique to adjudication of childhood
claims. SSA also will be measuring the performance of its quality
reviewers to ensure that they are accurately and consistently
identifying errors. Under this effort, SSA plans to increase its
sample of reviewed cases from 1,600 to 6,000 annually.
CONCLUSIONS
---------------------------------------------------------- Chapter 0:5
SSA has made substantial progress in implementing the new childhood
definition of disability through its rapid redetermination of most of
these cases, its action to ensure that the redetermination process is
fair, and its ongoing review of the implementation of the new
regulations. However, we remain concerned about how accurately and
consistently the disability determination process is working for
children. Specifically, because some of SSA's listings of
impairments require less than "two marked or one extreme" limitation
to qualify for benefits, SSA adjudicators are not assessing all
children against a uniform severity standard. This is because SSA
has neither updated its listings to reflect advances in medicine and
science nor modified them to reflect a single standard of severity,
despite its authority to do so. Moreover, we noted the need to
revise the listings 3 years ago. SSA also needs to continue its
efforts to improve decisionmaking for childhood cases to better
ensure that adjudicators apply the new eligibility criteria
accurately and consistently.
In view of the fact that many of SSA's medical listings for children
are outdated and allow eligibility to be based upon multiple
standards of severity, our May 1998 report recommended that the
Commissioner act immediately to update and modify its medical
listings to incorporate advances in medicine and science and to
reflect a uniform standard of severity. In its comments on our
report, SSA officials agreed that SSA should periodically update its
listings and stated that it is developing a schedule to accomplish
this. The agency stated that it must consult with medical experts to
ensure that the listings reflect state-of-the-art medical practice
and estimates that it will take several years to complete the
revision. However, the agency did not address the need for the
listings to reflect a uniform severity standard.
We will continue to monitor SSA's implementation of the new
eligibility criteria, including the agency's actions to update its
medical listings for children, as part of our mandate to report to
the Congress by 1999 on the impact of the changes to the SSI program
enacted by welfare reform. As part of that effort, we are monitoring
what SSA is doing to ensure the accuracy and consistency of childhood
disability decisions made under the new eligibility criteria.
-------------------------------------------------------- Chapter 0:5.1
Please contact me on (202) 512-7215 if you have questions about the
information presented in this statement.
RELATED GAO PRODUCTS
Supplemental Security Income: SSA Needs a Uniform Standard for
Assessing Childhood Disability (GAO/HEHS-98-123, May 6, 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).
*** End of document ***