United States G&O General Accounting Office Washiugtson, D.C. 20648 Ele8lth, Edncation ad Emnan Services Division B-278046 .- _ September 16, 1997 The Honorable William V. Roth, Jr. Chairman, Committee on Finance United States Senate The Honorable E. Clay Shaw . Chairman, Subcommittee on Human Resources Committee on Ways and Means House of Representatives Subject: SuDDlementaI Securim Income: Review of SSA Retiations Govetic Children’s Elitibilitv for the Program The Congress made the Supplemental SecuriQ Income (SST) eIigibiIity criteria for disabled children more restrictive in Public Law 104193, the Personal Responsibility and Work Opportunity Reconciliation Act, enacted in August, 1996 in order to help ensure that only needy children with severe disabilities be eligible for benefits. From the end of 1989 through 1996, the number of &ildren receiving SSI disability bentits more than tripled, from almost 300,000 to more than 1 million. This growth occurred after the Social Sqrity Administration (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..’ One regulatory change, implemented in December 1990, revised and expanded S&i’s medical listings for mental impairments by incorporating funcqional criteria into the listings and adding such impairments as attention d&i& hyperactivity disorder. The other regulatory change, implemented in February 1991 in response to the Sullivan v. Zeblev Supreme Court decision, added an individualized functional assessment (IFA) to SSA’s disability determination process as a basis for finding children eligible for SSI. Children who had previously been denied because their impairments did not meet or equal SSAG medical listings could now be found eligible if the IF’A determined that, their ISocial Securiix Rapid Rise in Children on SSTDisabiliti Rolls Follows New Regulations (GAOLEIEHS-94225,Sept. 9, 1994). GAOAEHS-97-220R Regulations on SSI Eligibility for Children B-278046 impairments substantially limited their ability to act and behave in age- appropriate ways2 On February 11, 1997, SSA issued interim final regulations tightening the eligibility criteria for children to receive SSI disability benefits3 The regulations, which became effective on April 14, 1997, implement legislative changes to the SSI disabled children’s program made by Public Law 104193. You asked us-under our responsibility to report on the effect of the legislative changes on the SSI program-to review the eligibility. criteria in the new regulations to determine their consistency with the law, focusing in particular on the provisions describing how severe a child’s impairment must be in order for the child to qualify for benefits.4 In addition to analyzing the regulations themselves and SSA’s regulatory analysis documenting its rationale for the new severity level, we reviewed the public comments on the regulations and intetiewed SSA officials. In summary, we found the agency’s regulations to be consistent with the law and well supported5 ELIGIBILITY CRITERIA IN REGULATIONS ARE . CONSISTENT WITH THE LAW AND WEXL SUPPORTED Public Law 104193 enacted se&ml provisions that made the eligibility criteria for disabled children more restrictive: (1) It changed the de&&ion of ?‘he medical listings for childhood impairments are regulations containing &r&t medical criteria for evaluating physical and mental impairments. 3Jnlight 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 Admini&ative Procedure Act, SSA issued interim final regulations with a request for public comments. SSA stated that it would issue revised rules if necessary. .. 4Section 232 of Public Law 104193 requires GAO to report on the effect of. these changes to the SSI program. _ - 5GA0 reported to the Senate Finance Committee and the House Ways and Means Committee that the regulations comply with the procedural steps required by sections 801(a)(l)(H)(i) through (iv) of title 5, U.S. Code. (See GAO/OGC-97-23,Feb. 26, 1997.) 2 GAOEIEHS-97-220R Regulations on SSI Eligibility for Children B-278046 childhood disability 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) it eliminated the IFA as a basis for determining eligibility for children, and (3) it removed maladaptive behavior from consideration when assessing a child’s personal/behavioral functioning. Thus, such behavior would be considered only once-in the assessment of that child’s social functioning-when dete rmining whether the child had a mental impairment severe enough to meet or equal the medical hstings.6 To implement the new law, SSA‘issued interim final regulations that defined an impairment that results in “marked and severe func@onal limitations” as one that meets or medically or functionally equals one of SSA’s medical listings. 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 skills, or an extreme limitation in one area. Under the previous IFA standard of severity, a child was generally found eligible 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 SSA also eliminated the IFA and removed the duplicate consideration of ma’ladaptive , behavior from the mental listings. During the public comment period for the draft regulations, SSA received more then 175 written comments from individuals and organizations, many of which expressed the view that the new eligibility standard in the regulations is more severe than the law requires. More recently, media reports have criticized the stringency of the new regulations. Many of the critics of the new standard of severity stated that an impairment that results in a marked limitation in one area and a moderate limitation in another is severe enough to meet the new statutcny definition of disability for children. SSA rejected the “one marked, one moderate” level of severity as the standard. Jn its regulatory analysis, SSA gave several reasons for concluding that the law and legislative history made clear that the Congress meant to establish a stricter level. First, the Congress eliminated the “comparable severity” standard ‘In taking legislative action, the Congress considered our findings on the subjective nature of the IFA process and the need to improve eligibility determinations for children with disabilities. See Social Securitx New Functional Assessments for Children Raise Eligibility Questions (GAO/HEX%+95- 66, Mar. 10, 1995). GAOIHEHS-97-220R Regulations on SSI Eligibility for ChiIdren B-278046 of disability, which had established an additional evaluation beyond the listings, and it eliminated the IFA, which was created for evaluating impairments that were less severe than those in the medical listings. Further, a “one marked, one moderate” standard of severity would have retained one of the standards under which children were found eli@ble under the IF’A, which SSA stated would violate the law. Finally, SSA interpreted the conference report accompanying the act as indicating the congressional intent that the listings would be the last step in the disability determination pro&s for children. We found the interim final regulations to be consistent with the law. We believe SSA was well within its authority in establishing the new level of severity, and its rationale for doing so was well supported. RESULTS OF REDETRRMINATSONSTO DATE ARE IN LINE WITH EXF’ECTATIONS The new eligibility criteria also apply to children already receiving SSI benefits. Public Law 104-193requires SSA to redetermine the eligibility of children .on the rolls who may not meet the new eligibility criteria because they received benefits on the basis of maladaptive behavior or the IFX Recipients can elect to continue benefit payments during the appeal process. SSA identified 288,000 chizdren as potentially affected by the changes in the eligibility criteria In its remtory analysis, it estimated that 135,000 children (46.9 percent) would lose benefits under the new eligibility criteria contained in the interim Gnal regulations. Through September 6, 1997, SSA has reviewed the eligibility of 246,211 of the 288,000 children. Of these, 116,670(47.4 percent) were found eligible to continue to receive benefits and 129,541 (52.6 percent) were found ineligible. Those continuing to be eligible include 86,595 children found eligible after initial redeterminations done by the state disability determination services . (DDS), 1,751 children found eligible by the DDSs upon appeal, and 28,324 .- : children who had been awarded benefits on the basis of an IF’A but whose impairments were now found through a file review to have been severe enough at the prior determination to qualify under the listings. For these latter cases, SSA modiEed its records to show that the awards were based on the listings and continued benefits to these children without further review. The 129,541 ineligible children include 6,624 who-were found ineligible for reasons other than disability and 122,917who were found ineligible after redetermination& including 966 found ineligible by the DDSs upon appeal. 4 GAO/HEHS-9?-220R Regulations on SSI Eli&biEty for Children B-278046 Because the number of children deemed to be ineligible by this review does not yet reflect the results of all appeals, we do not yet know what the l%naZ outcome on all these cases will be. Children initially deemed by a DDS to be ineligible have 60 days to request the DDS to reconsider their case. If they continue to receive an unfavorable result, they can appeal to an SSA administrative law judge, and, finally, to federal court. To date, 46.7 percent of the children with initially terminated benefits for whom the 60day appeal period has expired have appealed for a DDS reconsideration. Although SSA states that the early results of the redeterminations &mot be projected to the total number of redetermination$ required by the law, we believe the early results are in line with SSA’s expectations. We discussed a draft of this letter with .SSA officials responsible for these regulations. They agreed with our findings and made other technical comments, which have been incorporated where appropriate. Jf you have any questions about the information we have presented, please contact me on (202) 512-7215. Other major contributors are Cynthia Bascet@, Ellen Habenicht, and Daniel Schwimer. 4.k- Jane L. Ross Director, Income Security Issues (207019) 5 GAOIHEHS-97-220R Regulations on SSI Eligibility for Children c :...5 _“. - . .- - Ordering Information The first copy of each GAO report and testimony is free. Additional copies are $2 each. Orders-should be sent to the following address, accompanied by a check or money order made out to the Superintendent of Documents, when necessary. VISA and MasterCard credit cards are accepted, also. Orders for 100 or more copies to be mailed to a single address are discounted 25 percent. Orders by mail: U.S. General Accounting Office P.O. Box 37050 Washington, DC 20013 or visiti Boom 1100 700 4th St. NW (corner of 4th and G Sts. NW) U.S. General Accounting OfJice Washington, DC Orders may also be placed by calling (202) 512-6000 or by using fax number (202) 512-6061, or TDD (202) 512-2537. 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Supplemental Security Income: Review of SSA Regulations Governing Children's Eligibility for the Program
Published by the Government Accountability Office on 1997-09-16.
Below is a raw (and likely hideous) rendition of the original report. (PDF)