Supplemental Security Income:

Better Management Oversight Needed for Children's Benefits

GAO-12-497: Published: Jun 26, 2012. Publicly Released: Jun 26, 2012.

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What GAO Found

The number of Supplemental Security Income (SSI) child applicants and recipients with mental impairments has increased substantially for more than a decade, even though the Social Security Administration (SSA) denied, on average, 54 percent of such claims from fiscal years 2000 to 2011. Factors such as the rising number of children in poverty and increasing diagnosis of certain mental impairments have likely contributed to this growth. In fiscal year 2011, the most prevalent primary mental impairments among children found medically eligible were (1) attention deficit hyperactivity disorder, (2) speech and language delay, and (3) autism, with autism claims growing most rapidly since fiscal year 2000. State disability determination services (DDS) examiners also consider the impact of additional, or “secondary,” impairments when making a decision, and when present, these impairments were used to support 55 percent of those cases GAO reviewed that were allowed in fiscal year 2010. However, SSA has not consistently collected those impairment data, limiting its understanding of how all impairments may affect decisions.

DDS examiners generally rely on a combination of key medical and nonmedical information—such as medical records and teacher assessments—to determine a child’s medical eligibility for SSI. In its case file review, GAO found that examiners usually cited four to five information sources as the basis for their decision, and that being on medication was never the sole source of support for decisions. Moreover, examiners cited medication and treatment information, such as reports of improved functioning, as a basis for denying benefits in more than half of cases that GAO reviewed, despite a perception among some parents that medicating their child would result in an award of benefits. Examiners also reported they sometimes lacked complete information to inform their decision making. For example, several DDS offices reported obstacles to obtaining information from schools, which they believe to be critical in understanding how a child functions. Examiners also do not routinely receive information from SSA field offices on multiple children who receive benefits in the same household, which SSA’s fraud investigations unit has noted as an indicator of possible fraud or abuse. Without such information, examiners may be limited in their ability to identify threats to program integrity.

SSA has conducted fewer continuing disability reviews (CDR) for children since 2000, even though it is generally required by law to review the medical eligibility of certain children at least every 3 years. From fiscal year 2000 to 2011, childhood CDRs overall fell from more than 150,000 to about 45,000 (a 70 percent decrease), while CDRs for children with mental impairments dropped from more than 84,000 to about 16,000 (an 80 percent decrease). The most recent data show that more than 400,000 CDRs were overdue for children with mental impairments, with some pending by as many as 13 years or more. Of the more than 24,000 CDRs found to be 6 or more years overdue, 25 percent were for children expected to medically improve within 6 to 18 months of their initial allowance. SSA acknowledged the importance of conducting such reviews, but said that due to resource constraints and other workloads, such as initial claims, most childhood CDRs are a lower priority. SSA’s process for issuing waivers from the CDR legal requirement lacks transparency, and without these reviews, SSA could continue to forgo significant program savings.

Why GAO Did This Study

SSA’s SSI program provides cash benefits to eligible low-income individuals with disabilities, including children. In 2011, SSA paid more than $9 billion to about 1.3 million disabled children, the majority of whom received benefits due to a mental impairment. GAO was asked to assess (1) trends in the rate of children receiving SSI benefits due to mental impairments over the past decade; (2) the role that medical and nonmedical information, such as medication and school records, play in the initial determination of a child’s eligibility; and (3) steps SSA has taken to monitor the continued medical eligibility of these children.

To do this, GAO analyzed program data; interviewed SSA officials; conducted site visits to 9 field offices and 11 state DDS offices across the nation; reviewed a generalizable sample of 298 claims for select impairments from fiscal year 2010; reviewed relevant federal laws and regulations; and interviewed external experts, among others.

What GAO Recommends

GAO recommends that SSA take steps to ensure needed information, such as secondary impairment data and school records, is consistently collected; make its CDR waiver process more transparent; and conduct additional childhood CDRs. SSA agreed with four recommendations and disagreed with one that the agency conduct additional childhood CDRs, citing resource constraints. The GAO recommendation acknowledges resource constraints, as discussed more fully within the report.

For more information, contact Daniel Bertoni at (202) 512-7215 or bertonid@gao.gov.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: In July 2014, SSA released revised policy guidance to clarify the roles of disability examiners and medical or psychological consultants for determining appropriate diagnosis coding. The agency also added information for documenting "other impairments" to its Electronic Claims Analysis Tool (eCAT) and is reinforcing the new policy guidance in monthly meetings with Regional Directors. According to SSA, the revised guidance will help to ensure that disability determination services (DDS) examiners accurately record information on secondary impairments.

    Recommendation: To strengthen eligibility decisions and improve monitoring of children with mental impairments within the SSI program, the Commissioner of Social Security should direct the Deputy Commissioners of Retirement and Disability Policy and Operations to take steps to ensure that DDS examiners accurately record information on secondary impairments in order to improve SSA's understanding of how multiple impairments may influence decisions.

    Agency Affected: Social Security Administration

  2. Status: Open

    Comments: SSA stated that the agency and disability determination services (DDS) offices are aware of obstacles to obtaining school records, especially during summer months, and that Medical Professional Relations Office staff in the DDSs conduct school outreach as a regular business process. SSA noted that it has taken steps to schedule childhood continuing disability reviews (CDRs) during school sessions and that Medical Professional Relations Office staff are working directly with school counselors to obtain requested school information. However, SSA noted that initial claims and appeals are filed throughout the year and this continues to present challenges for the DDSs. Given that we found that school information is a key source for the DDSs in determining a child's medical eligibility for benefits, increased school outreach, coordination with the Department of Education, or guidance to the DDS offices may be needed.

    Recommendation: To strengthen eligibility decisions and improve monitoring of children with mental impairments within the SSI program, the Commissioner of Social Security should direct the Deputy Commissioner of Operations to identify the extent to which DDS examiners nationwide experience obstacles in obtaining teacher assessments and school records. To the extent these are identified, SSA should clarify the nature of these obstacles and formulate steps to address them. Such steps could include increased DDS outreach to primary and secondary schools, increased SSA coordination with the Department of Education, or additional guidance to DDS offices.

    Agency Affected: Social Security Administration

  3. Status: Closed - Implemented

    Comments: SSA reported that it published an administrative message on October 31, 2013 that reminds field office staff to notify the disability determination services (DDS) when more than one person within the same household is applying for, or receiving, Disability Insurance benefits or Supplemental Security Income disability payments, or both. The message also encourages staff to refer such cases to the fraud unit, if appropriate.

    Recommendation: To strengthen eligibility decisions and improve monitoring of children with mental impairments within the SSI program, the Commissioner of Social Security should direct the Deputy Commissioner of Operations to ensure that field offices notify their respective DDS offices of those claims in which multiple children within the same household are applying for or receiving SSI benefits so that examiners will be better able to identify potential fraud or abuse in the program and elevate these cases to the attention of SSA's fraud investigations unit.

    Agency Affected: Social Security Administration

  4. Status: Open

    Comments: SSA has received higher levels of program integrity funding in recent years and is making progress in addressing this recommendation. In fiscal year 2011, the year prior to GAO?s audit, SSA completed about 25,000 continuing disability reviews (CDRs) for SSI children (beyond those it is required to conduct for children who are low birth weight or who reach age 18). In each year since the audit, SSA has increased the number of CDRs conducted for SSI children, completing nearly 90,000 reviews in fiscal year 2014. SSA stated that with sustained, predictable funding, the agency will continue to work toward eliminating its CDR backlog for SSI children, an effort we believe is important for enhancing the program's integrity.

    Recommendation: To strengthen eligibility decisions and improve monitoring of children with mental impairments within the SSI program, the Commissioner of Social Security should direct the Deputy Commissioner of Quality Performance to eliminate the existing CDR backlog of cases for children with impairments who are likely to improve and, on an ongoing basis, conduct CDRs at least every 3 years for all children with impairments who are likely to improve, as resources are made available for these purposes.

    Agency Affected: Social Security Administration

  5. Status: Open

    Comments: In its May 2012 annual continuing disability review (CDR) report to Congress, SSA included a detailed description of how the agency meets its waiver requirements and also stated that the agency would begin issuing a formal waiver document in fiscal year 2012. Additionally, in December 2014, SSA issued letters to Representatives Dave Camp and Sander Levin, Committee on Ways and Means, and Senators Orrin Hatch and Ron Wyden, Committee on Finance, describing factors that SSA considered in exercising its waiver authority for fiscal year 2014. However, in its most recent publicly available CDR report to Congress, issued in October 2014, the agency only noted that a waiver refers to SSA's administrative discretion to determine the appropriate number of cases it will review on a state-by-state basis. We believe that the agency should make information on how it meets its waiver requirements available to the public on a regular basis to ensure the transparency of this process.

    Recommendation: To strengthen eligibility decisions and improve monitoring of children with mental impairments within the SSI program, the Commissioner of Social Security should direct the Deputy Commissioner of Quality Performance and Commissioner of Operations to take actions to ensure that SSA's CDR waiver process is open, transparent, and public. This may include promulgating formal guidance for issuing waivers, and a process for making information about issued waivers available to the public.

    Agency Affected: Social Security Administration

 

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