1). Number of Children Applying for and Receiving SSI Benefits Due to Mental Impairments Has Increased

The number of children applying for and receiving SSI benefits due to a  mental impairment has increased for more than a decade, and these  children comprise a growing majority of all child recipients on the SSI  disability rolls. Examiners Rely on a Combination of Key Information Sources to Determine Medical Eligibility

DDS examiners rely on a combination of key medical and nonmedical  information sources—such as medical records, effects of prescribed  medications, school records, and teacher and parent assessments—in  determining a child’s medical eligibility for benefits. Based on our case file review, we  estimate that examiners generally cited four to five information sources as  support for their decisions in fiscal year 2010 for the three most prevalent  mental impairments. In addition, several DDS officials told us  medication is considered in the context of other sources of information as  “just one piece of the puzzle.” Our case file review confirmed that  information on medication and treatment was never the sole source of  support for an allowance or denial. 6). By comparison, 47  percent of cases were denied and 53 percent were allowed when  medication was not reported as present. Examiners Sometimes Lack Complete Information to Inform Their Decision Making and Identify Potential Threats to Program Integrity

Despite the importance of nonmedical information in determining a child’s  medical eligibility, examiners sometimes face challenges obtaining  complete information. In addition to the challenges they sometimes face in obtaining information  from schools, DDS examiners said that they do not routinely receive  information from SSA field offices on multiple siblings receiving SSI  benefits within the same household even though they are directed to be  alert for such cases. Without information on such  children, DDS examiners may be limited in their ability to identify potential  fraud or abuse in the program and elevate these cases to the attention of  SSA’s fraud investigations unit. SSA Has Conducted Few Childhood CDRs in Recent Years

SSA has conducted significantly fewer CDRs for children receiving SSI  benefits since 2000, even though SSA is generally required to perform  CDRs at least every 3 years on child recipients under age 18 whose  impairments are likely to improve, as well as certain other individuals (see  fig 7). Childhood CDRs overall fell from more than 150,000 in fiscal year  2000 to about 45,000 reviews in fiscal year 2011 (a 70 percent decrease). More specifically, CDRs for children under age 18 with mental  impairments declined from more than 84,000 to about 16,000 (an 80  percent decrease). From fiscal years 2000 to 2011, the number of adult  CDRs fell from 584,000 to 179,000.proportion of childhood CDRs conducted has remained much lower than  the proportion of adult CDRs conducted. because DDS offices have not consistently collected secondary  impairment data. However,  because SSA considers SSI childhood CDRs a lower priority than other  CDRs, it is unclear whether the agency will use this funding to review  children most likely to medically improve—reviews that could yield a high  return on investment. If SSA continues to rely heavily on the use of  waivers to conduct fewer CDRs than would otherwise be required by law,  SSA will potentially forgo future program savings. 3. Direct the Deputy Commissioner of Quality Performance and Deputy  Commissioner of Operations to take actions to ensure that SSA’s  CDR waiver process is open, transparent, and public. Appendix I: Scope and Methodology

Our review focused on (1) the trends in the rate of children receiving  Supplemental Security Income (SSI) benefits due to mental impairments;  (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 the Social Security Administration (SSA) has  taken to monitor the continued medical eligibility of these children. Our work included site  visits to 9 field offices within these regions, as well as 11 state disability  determination services (DDS) offices (state agencies under the direction  of SSA that perform medical eligibility determinations and continuing  disability reviews of SSI applicants). In addition,  we interviewed numerous external experts from the medical and disability  advocacy communities and reviewed relevant studies to identify factors  that may be currently affecting the growth and composition of the  childhood disability applicants and recipients, especially for those children  with mental impairments. We also reviewed relevant federal  laws and regulations. Appendix III: Trends on the Three Most Prevalent Primary Impairments among Children with Mental Impairments in the Supplemental Security Income Program

Social Security Administration (SSA) data show that the three most prevalent  primary mental impairments among those children allowed for Supplemental  Security Income (SSI) benefits in fiscal year 2011 were for (1) attention  deficit disorder or attention deficit hyperactivity disorder (ADHD), (2) speech  and language delay, and (3) autistic disorder and other pervasive  development disorders (autism). From fiscal years 2000 to 2011, applications for this condition as a  primary impairment more than doubled, from about 55,204 to 124,217,  while allowances have also doubled from 13,857 to 29,872 (see fig. Autism.
Why GAO Did This Study

SSAs 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 childs 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 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 informationsuch as medical records and teacher assessmentsto determine a childs 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 SSAs 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. SSAs process for issuing waivers from the CDR legal requirement lacks transparency, and without these reviews, SSA could continue to forgo significant program savings.

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.