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)

      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
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

ELIGIBILITY CRITERIA IN REGULATIONS ARE                                         .

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

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

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.


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

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
       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


       5          GAOIHEHS-97-220R        Regulations   on SSI Eligibility   for Children

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