Social Security Disability Evaluation for Adults with Congenital Heart Defects

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1 Social Security Disability Evaluation for Adults with Congenital Heart Defects Paul Quick, M.D. Adult Congenital Heart Association Conference April 30, 2011 Los Angeles

2 Outline Overview of U.S. disability safety net SSI and SSDI How to apply and appeal Five-step determination process The Social Security listings of impairment Evaluating ability to do prior work Evaluating ability to do any other work with review of levels of work Returning to Work

3 Disability Safety Net in the United States Social Security Railroad Retirement State- and local-employee pension funds State disability insurance Workers Comp Family and Medical Leave Act State vocational rehabilitation programs Private disability insurance Various state and local welfare programs Charitable assistance Americans with Disabilities Act

4 This presentation is only about U.S. Social Security but Railroad Retirement and the Canada Pension Plan use similar criteria for disability determination.

5 2 types of Social Security benefits Social Security Disability Insurance Supplemental Security Income

6 Social Security Disability Insurance (SSDI) Insurance based on work credits. Credits based on income subject to OASDI or FICA or self-employment tax (1 credit per $1120 earnings) 4 credits possible per year; credits are sometimes called quarters but they are not related to calendar quarters

7 SSDI (cont.) Financial eligibility based on age and credits Under 24: 6 credits in 3 years 24-30: Credit for half of time since age 21 Over 30: 20 credits in last 10 years of work.

8 SSDI Adults age may qualify if they meet medical requirements, AND A parent or custodial grandparent receives Social Security benefits or has died.

9 SSDI (cont.) Dollar amount of benefit is based on how much OASDI/FICA/self-employment tax you ve paid over your lifetime. Benefits begin for most recipients after five full months of disability.

10 Supplemental Security Income (SSI) For disabled people with little or no income and assets less than $2000 Values of primary residence and car are excluded For students, money saved in an educational plan can be excluded. For students under age 22, income up to $1640/month and $6600/year is not counted against SSI eligibility.

11 SSI (cont.) Federal benefit is $674 for individuals, $1011 for couples. States may supplement this to pay a higher amount. If SSDI benefit is less than the SSI amount, a partial SSI benefit is added to achieve federal benefit amount, if claimant is financially eligible for SSI.

12 SSI (cont.) Parents assets/income not counted after age 18 Adults do not have to have a work record or a parent on Social Security in order to qualify.

13 Best Practice Recommendation Review impairments and financial eligibility for young adults at the time of transition to adult care.

14 Medical benefits Medicare-eligible after 24 months of SSDI benefits Some states, but not all, give Medicaid benefits to all SSI recipients. 2014: Medicaid will be expanded to everyone below 133% federal poverty level, regardless of ability to work

15 Online application File at You will be asked to come to SSA in person to complete application process A state government agency in your state will evaluate your case in accordance with federal rules.

16 Application Process A complete medical record with a letter from doctor helps win at initial evaluation. It is best to have the letter done in advance and bring it with you to the first visit to Social Security If denied, you have 65 days to request reevaluation. You may add information at this stage. If you haven t already submitted a letter from the doctor, this is another chance.

17 Application Process (cont.) If rejected at initial consideration and reconsideration at the state level, you can appeal to a federal hearing officer at Social Security. Most dockets have a 2-3 year delay. If you haven t hired a lawyer, you should get one for the hearing process. Lawyers sometimes can get on the record approvals without waiting for the hearing date.

18 Application Process (cont.) Agency may send you to a physician who has a contract with them to provide evaluations. However, if a treating doctor has given a letter and records at the beginning of this process, the independent exam is usually not required. If exam is required, make sure your own doctor has sent all records, and ask if your own doctor can do the evaluation. Doctor must use criteria in Green Book ( to document adequate exam.

19 How Social Security Decides (5 Steps) 1.Is there a severe impairment that has lasted or will last >1 yr, or will result in death? 2.Do you have substantial gainful activity ($1000/mo or more from work)? 3.Does impairment meet or equal a listing in the Blue Book? If yes, no further evaluation; claim is approved. 4.Are you physically able to do prior work? (any work done in last 15 years) 5.Can you do any other full time work?

20 It s not about your BEST DAY......but whether, despite your impairments, you can carry out a normal 5-day, 40-hour workweek.

21 If it s not in the DOCTOR S record......it s not considered documented, and the agency can t consider it.

22 Impairment vs. Disability Doctor DOCUMENTS IMPAIRMENT Administrative process DETERMINES DISABILITY

23 Patients: Make sure doctor documents symptoms at every visit. What can t you do because of your condition? (GIVE SPECIFICS) Follow recommended therapy EXCEPTIONS: Treatments may be refused if you have reasonable concerns about risks, or can t tolerate side effects You can t understand or remember Dr. s instructions. DOCTOR MUST DOCUMENT)

24 PRACTICE is a summary letter Document qualifications and length of relationship with pt. ( Treating physician 3 visits) Document educational level and significant work history, including any limitations on schooling or work due to condition. Document if patient meets listings per Blue Book. Document if patient has any combination of impairments equivalent to any listing. Be specific. Document cognitive, developmental, or behavioral issues you are aware of, esp. syndromic conditions and cognitive impairment due to low O2 levels (acute or chronic) Mid-level or other personnel may write letter, but it must be signed or countersigned by a PHYSICIAN.

25 Special note on substance disorders If impairment would be present even in the absence of a substance use disorder--or if Dr. can t tell if the impairment would be present--the claim is supposed to be granted. However, this usually requires filing an appeal and going to a hearing. Evaluation of symptoms during a prolonged period of abstinence strengthens the case if impairment is still present.

26 Social Security Listing of Impairments Listings are contained in the book Disability Evaluation under Social Security available at ebook/index.htm a/k/a the BLUE BOOK. The Blue Book contains adult and pediatric sections.

27 Cardiac listing relevant to ACHD Adults with cardiac impairments may qualify under one or more cardiac listing, e.g.: 4.02 Chronic heart failure 4.04 Ischemic heart disease 4.05 Recurrent arrythmias 4.06 Symptomatic congenital heart disease 4.09 Heart transplant

28 4.02 Chronic heart failure Systolic failure with LVEDD 6 cm or EF 30%; or Diastolic failure with LAD 4.5 cm or septal + posterior wall thickness 2.5 cm and Functional criteria too numerous to list (see the Blue Book at ndex.htm)

29 4.04 Recurrent arrhythmia Syncope or near-syncope in conjunction with recurrent documented episodes of arrhythmia, not controlled despite prescribed medications

30 4.06 Symptomatic CHD Cyanosis plus hematocrit 55% or O2 sat 90% or SaO2 60 torr; or Intermittent left-to-right shunt with cyanosis on exertion at 5 METs and a PaO2 60 torr; or PA pressure 70% of systemic pressure

31 4.09 Heart transplant Patients are considered disabled for one year after transplant. Eligibility for transplant is not conidered a listinglevel impairment by itself. Prior to transplant, patients are evaluated under other relevant listings. After one year, transplant recipients may continue to be disabled by other impairments, but these must be documented.

32 Documenting listing-level impairment Best practice recommendation for professionals: Review all organ systems with obvious impairments Professionals can and should report any clinically obvious impairment, including mental health impairments, regardless of their own specialty.

33 Doctor s letter: Best practice recommendation Write: With regard to listing X.XX, the patient has the following findings:..., or In my clinical opinion, this patient s functional ability is equal to what is described in listing X.XX in the following ways:... Do not write, Patient meets listing X.XX. Remember, the doctor documents impairment; the agency determines disability.

34 What if the condition doesn t fit these listings? Doctor must document how the impairments are functionally equivalent to these or any other listings in the Blue Book; or Show how the impairments prevent patient doing prior work (whether or not jobs are available), AND Depending on patient s age and education, show how patient is unable to any other full-time work.

35 Ability to do prior work Document work history in doctor s letter Include examples of tasks that pt was unable to do, excessive absence, terminations for poor performance, etc. due to medical impairment Include all components of illness and their effects, including behavioral and cognitive impairments due to hypoxia, brain injury, associated syndromes

36 Ability to do other work Doctor to document ability to sit, stand, walk, crouch, stoop, lift, crawl, climb, or use hands in the course of a normal workday. A patient who naps frequently due to fatigue has these activities limited by fatigue.

37 Ability to do other work Document ability of patient to listen, understand, and carry out instructions with normal concentration, persistance, and pace. Document educational history; there are special rules for people with low educational attainment and either a history of hard labor or poor participation in the workforce.

38 Documenting FATIGUE Document hours of sleep per week. Requiring 10 hours of sleep per 24 hours is an important objective threshold of fatigue causing impairment. Document specific activities that patient has reduced or eliminated due to fatigue. Example: The patient was unable to attend her daughter s wedding due to fatigue is more powerful than simply writing that The patient complains of fatigue.

39 Definition of Sedentary Work Must be able to work an 8-hour workday and a 40-hour work week with normal breaks. Must be able to stand or walk for 2 hours and sit for up to 6 hours per day. Must be able to lift 10 lbs occasionally

40 Sedentary work (cont) A patient who can t do sedentary work as defined above, is considered disabled because they can t do ANY work. Example: desk job

41 Light work Must stand and walk for six hours, able to lift 20 lbs occasionally; 10 lbs frequently. Examples: cashier, stocker, security

42 Moderate work Constant standing, walking. Lift 50 lbs occasionally, 25 lbs frequently. Examples: plumber, electrician, floor nurse

43 Heavy work Constant standing, walking, heavy lifting. Example: construction laborer

44 For ALL work Must be able to understand and follow directions with normal concentration, persistence, and pace, Must be able to interact with others as necessary to perform work functions, AND Must be physically able to manage transportation to and from work.

45 Special rules Worn-out worker. A manual laborer over age 55 with low educational level is disabled if he or she has any significant impairment. Lack of work history: A worker with little or no history of work outside the home, who has less than an 11th grade education, is considered disabled if he or she has any significant impairment

46 What happens if you get better? Patients are required to report to Social Security if their illness improves enough that that they are no longer impaired. This is a PATIENT responsibility, not a DOCTOR responsibility. Social Security may require a continuing disability review (CDR) at any time. Benefits may be terminated and prior benefits may have to be repaid if the disability no longer exists.

47 Return to work: Financial benefits You must notify SSA if you return to work. Failure to do so may trigger a requirement to return benefits. SSDI payments continue until you have had 9 months of substantial gainful activity in a rolling 60-month period. SSI: Benefits reduced 1:2 for earnings over $65/ mo. Certain work expenses are excluded from counting against reduction of benefits.

48 Return to work: Medical benefits Medicare benefits continue for at least 93 months if you return to work and report your earnings to SSA. Medicare may be continued indefinitely if you are still disabled, even if you work. Medicaid benefits may continue if you were eligible for Medicaid before you started work, and need your benefits in order to continue working.

49 Return to work: Ticket To Work Program Social Security will assist recipients returning to work. You may use a Social Security-approved employment network or a vocational rehab program to help you return to work. Disability review is suspended. You will not be subject to repayment of benefits if you return to work under a Ticket To Work.

50 Return to work: Plan for Self-Sufficiency (PASS) SSI recipients may exclude assets for education or training in order to enter or reenter the work force, or to start a business in order to become self-sufficient

51 Outline Overview of U.S. disability safety net SSI and SSDI How to apply and appeal Five-step determination process The Social Security listings of impairment Evaluating ability to do prior work Evaluating ability to do any other work with review of levels of work Returning to Work