Medical Assistance & SSI Eligibility

David Gates, Pennsylvania Health Law Project

The following is an update of Medical Assistance (MA) and SSI eligibility. This information replaces all earlier articles concerning regulations and information about MA and SSI.

Families who have children with emotional, behavioral or mental disorders are often asked to apply for Medical Assistance for their child in order to access services (such as wraparound or residential treatment facilities) not commonly covered by regular health insurance. Children in families with very limited incomes can qualify for Medical Assistance under a program called Healthy Beginnings. A child does not need to have a disability to qualify under Healthy Beginnings. However, a child's parent(s) income helps to determine the child's eligibility under Healthy Beginnings.

Most other children who have emotional, behavioral or mental disorders qualify for Medical Assistance either by qualifying for SSI (which automatically provides Medical Assistance) or under a special rule, commonly know as the "loophole" (category "PS 95") under which parental income is not counted. In order to qualify for SSI or Medical Assistance under the loophole, the child's emotional, behavioral or mental disorder must be severe enough to meet Social Security's disability standards. [Even though Medical Assistance does not go through Social Security, its uses SSA's disability standards.] Many parents have asked what disability standards their child must meet to qualify for Medical Assistance. This article discusses the standards.

IEP not enough

The fact that a child has an Individualized Education Plan (IEP) and is in special education or early intervention does not, by itself, mean the child meets the disability standards for Medical Assistance or SSI. The eligibility standards for special education and early intervention are completely different from the Social Security and Medical Assistance disability standards. However, the Comprehensive Evaluation Report (CER) which is usually done prior to an IEP can be an excellent source of documentation of the kinds of factors considered in the Social Security/Medical Assistance disability standard.

Diagnosis not enough

Having a particular diagnosis is not enough to meet the disability standards. There are two parts to the disability standards: diagnosis and functional impairment. The standards contain criteria that specify the characteristics of the various mental illnesses and bio-neurological disorders by general diagnostic category that meet the diagnosis part of the disability standards. However, a child can still meet the diagnosis part of the standards if his or her condition is "equivalent" to one of the disorders listed in the criteria.

Functional impairment is the key

The second part of the disability standards is functional impairment. Documenting a level of functional impairment that meets the disability standards is absolutely essential in order to qualify either for Medical Assistance under the "loophole" or for SSI, regardless of the child's diagnosis.

Four areas of function

The disability standards group areas of functioning into four areas. In most cases, the child must have a "marked limitation" in at least two of the four areas of functioning in order to meet the standards. The four areas are:

1. cognitive/communicative functioning;
2. social functioning;
3. personal functioning; and
4. concentration, persistence and pace.

What the four areas of functioning mean

1. Cognitive/communicative functioning: Cognitive functioning refers to intelligence as measured by standardized intelligence tests. A child with both cognitive limitations and speech or other communicative limitations will still have to have a limitation in another area in order to meet the disability standards.
2. Social functioning refers to a child's capacity to form and maintain relationships with parents, other adults and peers.
3. Personal functioning pertains to self-care; i.e., personal needs, health, and safety (feeding, dressing, toileting, bathing; maintaining personal hygiene, proper nutrition, sleep, health habits, adhering to medication or therapy regimens, following safety precautions).
4. Concentration, persistence and pace refer to the ability to complete tasks in a timely manner.

What "marked limitation" means

Remember that to meet the Social Security/Medical Assistance disability standards, the child must have "marked limitations" in two of the four areas of functioning listed above. A "marked limitation" is defined in the regulations as "more than moderate but less than extreme ... such as to interfere seriously with the ability to function (based upon age-appropriate expectations) independently, appropriately, effectively, and on a sustained basis.

When standardized tests are used as the measure of functional parameters, a valid score that is two standard deviations below the norm for the test will be considered a marked restriction." (Listing 112.00(A) at 20 CFR §404, Subpart P, Appendix 1.) In determining whether the limitation is "marked", Social Security and Medical Assistance will consider the intensity, frequency, and duration of the behaviors or other functional limitations.

Documentation is essential

Some documentation of the child's diagnosis and the behaviors and functional impairments that were considered in making the diagnosis must come from a physician (most commonly a psychiatrist) or a psychologist. Don't assume the psychiatrist or psychologist knows the disability standards. It is very helpful for the parent/guardian or other person working with the child to remind the psychiatrist, psychologist and/or other treatment professionals of behaviors or other functional limitations that are relevant under one or more of Social Security's four areas of functioning so these behaviors can be noted in the treatment professional's report.

Remember, it is crucial that these reports not only mention behaviors that are relevant to the four areas of functioning, but that the reports also include observations as to the intensity, frequency and duration of the behaviors or other functional limitations. In addition, it is useful to provide records from prior hospitalizations or records from residential placements or outpatient treatment. School records, especially the CER, also can be useful if they indicate problems relevant to the four areas of functioning. Any other individual who has direct knowledge of the child's behaviors or other functional limitations can supplement the documentation.

Who gets the documentation?

If applying for Social Security SSI, will send out questionnaires to doctors, therapists and teachers. The parent/guardian should strongly encourage the professionals receiving the Social Security disability questionnaires to fill them out completely and promptly. Social Security will often obtain hospital records as well. However, Medical Assistance will not send questionnaires or get hospital records. Obtaining the necessary medical and psychiatric documentation is the responsibility of the parent/guardian when applying for Medical Assistance.

What happens next for Medical Assistance?

For Medical Assistance, the caseworker at the County Assistance Office has authority to find that the child meets the disability standards, pending a final decision if, based on the documentation provided by the parent/guardian, the child "appears to be disabled." (Medical Assistance Eligibility Handbook §305.26.) This is known as "presumptive eligibility" and is very common if good documentation is provided.

After that the caseworker is supposed to transfer the case to the Disability Advocacy Program Unit (DAP Unit) which usually reviews the documentation, and may request that the parent/guardian get additional documentation or come in for an interview. After that, the DAP Unit is supposed to send the documentation to an agency under contract with Medical Assistance, know as the Medical Review Team (MRT) which makes the final decision as to whether the documentation shows that the child meets the disability standards.

If the MRT decides that the child's documented condition does not meet the disability standards, the County Assistance Office will terminate the child's Medical Assistance unless the child is eligible under another category. However, the parent/guardian can appeal the MRT's decision, and if their appeal is received by the County Assistance Office within 10 days of the termination notice being mailed, the termination cannot go through until after the family has had a hearing and gets a hearing decision. (Of course, if the family wins, the termination won't go through at all.) The termination notice explains how to appeal.

What happens next for SSI?

SSI also has the authority to make an immediate decision that the child meets the disability standards. Social Security calls this "presumptive disability." Unfortunately however, children with mental illnesses or bio-neurological disorders other than mental retardation are rarely found presumptively disabled by Social Security. This means the child is not likely to obtain Medical Assistance through SSI for several months (sometimes a year for more) until the full disability determination process is completed.

Because of this, it is usually necessary for the parent/guardian to apply separately for Medical Assistance at the County Assistance Office while waiting for a decision on the SSI because the child can usually get Medical Assistance more quickly than SSI. After the SSI application is filed, the case is referred by Social Security to the Department of Labor, Bureau of Disability Determination. It sends out questionnaires, obtains hospital records and may even send the child to another psychologist or psychiatrist (at Social Security's expense) for what is called "a consultative exam." The Bureau of Disability Determination then makes a recommended decision which Social Security finalizes and sends out. The parent/guardian can appeal that decision if it is unfavorable.

If Social Security finds that the child does not meet the disability standards and the child had been receiving Medical Assistance while waiting for the Social Security decision, it is critical that the parent/guardian appeal the Social Security denial, even if the SSI cash benefit is not that important to the family. This is because a finding by Social Security that the child does not meet the disability standards is binding on Medical Assistance. Therefore, if the child had been receiving Medical Assistance under the loophole or Healthy Horizons, under which the child must meet the disability standards in order to qualify, Social Security's decision that the child does not meet the disability standards will result in the child losing their Medical Assistance as well.

The full disability standards are available on the Internet at http://www.ssa.gov/OP_Home/cfr20/404/404-ap09.htm. The formal name for the disability standards is the "Listing of Impairments." The first half of the listings applies to persons 18 and older. The second half applies to children under age 18 and begins with section 100.00. The standards (or listings) for "mental disorders" begin at section 112.00.

For more information call the PA Health Law Project at 1-800-274-3258.

Correction: Posted: September 10, 2000. The "loophole" is only for Medical Assistance, not SSI. Income of the parent with whom the child is living counts in determining eligibility for SSI, regardless of the type of disability, unless the child is 18 or older or the child has been out of the home (e.g. in a hospital, residential treatment facility [RTF], foster home or other residential setting) for at least one (1) full calendar month.

Parents Involved Network (PIN), a project of
Mental Health Association of SE PA
1211 Chestnut Street, 11th Floor
Philadelphia, PA 19107
215-751-1800 or 800-688-4226
Email: law@pinofpa.org