	Background

Since 1974, the SSI program, under Title XVI of the Social Security Act,  as amended, has provided benefits to low-income blind and disabled  persons, including adults and children as well as certain aged individuals  who meet financial eligibility requirements and SSA’s definition of  disability. After initial verification, the field office  transmits the case file to their state disability determination services office  for a medical evaluation. Number of Children Applying for and Receiving SSI Benefits Due to Mental Impairments Has Increased

The numbers of children applying for and receiving SSI benefits due to a  mental impairment has increased over the past decade and now  comprise a growing majority of all child beneficiaries. 2). Our preliminary research suggests that several factors may  have contributed to the increased number of child applicants and  beneficiaries, including but not limited to SSA’s and child advocates’  outreach efforts, improved access to health insurance for children, the  rising number of children living in poverty, and increased diagnosis of  certain mental impairments. However, the relative effects of these and  other factors on program growth are not fully known at this time. While it is unclear how various factors are contributing to growth at this  time, SSA data show that since fiscal year 2000, children with mental  impairments have represented the majority of all child applications and  medical allowances for SSI benefits. 3). As of December 2010, about  95,000 (11 percent) children with mental impairments were receiving SSI  benefits due to autism. Examiners Report Using a Combination of Key Information Sources in Determining Medical Eligibility

In our preliminary work, DDS officials reported that they rely on a  combination of key medical and nonmedical information—such as  medical records, prescribed medications, school records, and teacher  and parent assessments—in determining a child’s medical eligibility. Several DDS officials said that when making a determination, they  consider the totality of information related to the child’s impairments,  rather than one piece of information in isolation. In response to concerns among many about the role medication plays in  the determination process, we asked SSA and DDS officials how  information about a child’s use of prescribed medications is used, and  they told us it is generally given no more weight than any other medical or  nonmedical information in determining a child’s medical eligibility. Several DDS officials told us school records  and teacher assessments (standardized questionnaires) are especially  critical, because these assessments provide information on the child’s  functioning over time and are generally more objective than parent  assessments. Despite the importance of nonmedical information in determining a child’s  medical eligibility, our preliminary work shows that examiners sometimes  face challenges obtaining complete information. SSA Has Conducted Significantly Fewer CDRs for SSI Children with Mental Impairments

SSA is required to periodically review the medical eligibility of certain  individuals, though our preliminary work shows that SSA has conducted  significantly fewer CDRs for children receiving SSI benefits in recent  years, including those with mental impairments. Between fiscal years  2000 and 2010, childhood CDRs for those recipients under age 18 and  age 18 redeterminations overall fell from more than 200,000 to about  126,000 (a 38 percent decrease), and more specifically, childhood CDRs  for those with mental impairments declined from more than 84,000 to  about 13,000 (an 84 percent decrease) (see fig. SSA has recently estimated that  that the CDR process yielded a savings-to-cost ratio of roughly $12.50 to  $1 in fiscal year 2009, and that those CDRs conducted for adults and  children combined in fiscal year 2009 will save federal programs an  estimated $4.6 billion. SSA and DDS officials have acknowledged that the agency is not  conducting reviews for child recipients in a timely manner, and in some  cases, they have not conducted required childhood CDRs prior to a  child’s age 18 redeterminations.
Why GAO Did This Study

The Social Security Administration's (SSA) Supplemental Security Income (SSI) program provides cash benefits to eligible low-income disabled individuals, including children, as well as certain others. Children may generally qualify for SSI benefits if they meet certain financial requirements and are deemed to have a qualifying medically determinable physical or mental impairment of a specified duration or severity that results in a functional limitation. In 2010, SSA paid more than $9 billion to about 1.2 million disabled children. Over the past decade, the overall number of children receiving SSI benefits has continued to rise. In this statement, GAO discusses initial observations from its ongoing review and examines (1) the 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 medical eligibility; and (3) the steps SSA has taken to monitor the continued medical eligibility of these children. To examine these issues, GAO analyzed program data, interviewed SSA officials, conducted site visits to SSA field offices and state disability determination services (DDS) offices, and interviewed external experts. This work is ongoing and GAO has no recommendations at this time. GAO plans to issue its final report in April 2012.

What GAO Found

The numbers of children applying for and receiving SSI benefits due to a mental impairment has increased over the past decade and now comprise a growing majority of all child beneficiaries. While more than half of child applicants are denied each year, children with mental impairments, such as autism, have represented a growing share of those medically allowed for benefits--increasing from 60 to 67 percent between fiscal years 2000 and 2010. Factors including but not limited to the rising number of children living in poverty and increased diagnosis of certain mental impairments may have contributed to such growth. However, the relative effects of these and other factors on program growth are not fully known at this time. Generally, DDS officials reported that they rely on a combination of key medical and nonmedical information--such as medical records and teacher and parent assessments--in determining a child's medical eligibility and that they consider the totality of information related to the child's impairments, rather than one piece of information in isolation. For example, SSA and DDS officials said that they consider a child's use of prescribed medications in the context of other information including school records and teacher assessments, which are critical in evaluating the child's functioning over time. Yet, despite the importance of such nonmedical evidence, GAO's work shows that examiners sometimes face challenges in obtaining this information partly due to teachers' reluctance to complete the assessments. SSA is required to periodically review the medical eligibility of certain children receiving SSI benefits, but GAO's work shows that SSA has conducted significantly fewer childhood continuing disability reviews (CDR) in recent years. Between fiscal years 2000 and 2010, the number of childhood CDRs and age 18 reviews overall fell from more than 200,000 to about 126,000 (a 38 percent decrease), while childhood CDRs for those with mental impairments dropped from more than 84,000 to about 13,000 (an 84 percent decrease). SSA officials have acknowledged that the agency is not conducting childhood CDRs in a timely manner mostly due to resource constraints. However, SSA recognizes the importance of conducting CDRs and has recently estimated that the CDR process yields a savings-to-cost ratio of $12.50 to $1.