Medical Information and SSA Disability Criteria

SSA's Definition of Child Disability

SSA's definition of disability differs from a medical or educational definition. For adults, the definition focuses on a person's ability to work so that he or she can earn SGA despite limitations. For children, eligibility for SSI disability is based on the child's limitations compared to other children of the same age without impairments.

It is very important for you to keep SSA's definition of disability for children in mind as you work with an applicant. Understanding SSA disability criteria helps the SOAR case manager assess the documentation necessary to support the child’s claim of disability.

• “If under 18, whether or not married or head of household, the child has:
  • A medically determinable physical or mental impairment or combination of impairments which result in marked and severe functional limitations, and
  • The impairment(s) has lasted or can be expected to last for a continuous period of at least 12 months or be expected to result in death.”

• For more information, you can revisit SSA: What is Disability? in Class 1.

Significant Functional Limitations

Information about a child’s functional limitations is a critical component of SSA’s assessment of SSI eligibility for children.

For a child to qualify for SSA disability benefits due to a mental impairment, the application must provide information illustrating significant functional limitations clearly tied to the child’s conditions.

• For mental disorders, in Step 3 of the sequential evaluation, DDS assesses limitations in four areas of mental functioning (known in the listings as the "paragraph B" criteria):
  1. Understand, remember, or apply information
  2. Interact with others
  3. Concentrate, persist, or maintain pace
  4. Adapt or manage oneself

Children may qualify for SSI based on physical illnesses or conditions if they meet certain severity criteria, which differs for each condition. Their physical or mental impairment(s) might also be found to functionally equal the listings .

• To assess functional equivalence, SSA considers how a child functions in activities in terms of six domains:
  1. Acquiring and using information
  2. Attending to and completing tasks
  3. Interacting and relating with others
  4. Moving about and manipulating objects
  5. Caring for yourself
  6. Health and physical well-being

These domains are broad areas of functioning intended to capture all of what a child can or cannot do.

Medically Determinable Physical and/or Mental Impairment

What is a "Medically Determinable Impairment"?

A medically determinable physical or mental impairment is an impairment that results from anatomical, physiological, or psychological abnormalities that can be shown by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established by objective medical evidence from an acceptable medical source. SSA does not use a person’s statement of, symptoms, a diagnosis, or a medical opinion to establish the existence of an impairment(s).

The Listing of Impairments

The severity of the illness(es)/condition(s) must meet, or be medically equivalent to, the criteria of a listing.

• The Listing of Impairments is generally referred to as “the listings” and can be accessed on the SSA website.
• The listings are categorized by body system (i.e., cardiovascular, musculoskeletal, mental disorders).
• The listings contain two parts – Part A applies to the evaluation of impairments in adults age 18 and over, and Part B applies only to the evaluation of impairments in children under age 18 (the children’s series are in the one hundred numbers).
• The criteria in the listings are updated regularly to reflect advancements in treatment, prognosis, and recovery.

Diagnoses

Disability can be based on limitations from one or a combination of illnesses. If a child has a serious mental illness and physical health issues, the combination may meet the disability criteria.

• Note that the mental disorders in the listings are presented differently from the disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association (APA) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10).
• The mental disorder listings include severity criteria for each category of mental disorders, including the functional criteria by which DDS assesses a child’s ability to function age-appropriately in four areas of mental functioning in a manner comparable to that of other children the same age who do not have impairments.

Documentation

The medically determinable mental impairment must be documented in medical records, laboratory reports, or other clinical findings of an Acceptable Medical Source (AMS).

• An AMS may be a:
  • Doctor (MD/DO/PhD/EdD/PsyD)
  • Advanced Practice Registered Nurse (APRN), which includes: Certified Nurse Midwife, Nurse Practitioner, Certified Registered Nurse Anesthetist, and Clinical Nurse Specialist
  • Physician Assistant
  • Audiologist
  • School Psychologist
  • Speech Language Pathologist
• DDS prefers that medical evidence come from an ongoing treatment provider
• DDS reviews the documentation for the severity of the illness

Useful sources of evidence are summarized in the SOAR tool: Medical and Functional Information for SSI.

Duration

SSA’s Definition of Duration

The limitations tied to the illness(es) must have “lasted or be expected to last 12 months or more or be expected to result in death."

• SSA does not have a “short-term” disability program