Childhood Continuing Disability Reviews and Age-18 Redeterminations for Supplemental Security Income Recipients: Outcomes and Subsequent Program Participation

Summary

This note presents statistics on the return to disability program participation of child Supplemental Security Income (SSI) recipients whose eligibility had ceased because of a finding of medical improvement in a childhood continuing disability review (CDR) or an age-18 redetermination. The study supplements previous work on program return among adults. We estimate that about 9 percent of children who qualified for SSI payments because of low birth weight (LBW) returned to the SSI rolls within 10 years of having their eligibility ceased for medical improvement. About 13 percent of non-LBW children returned to the rolls within 10 years of a cessation decision, and about 10 percent returned before reaching age 18. Finally, we find that about 14 percent of youths returned to SSI within 10 years of a cessation decision in an age-18 redetermination. These statistics provide context for policy proposals calling on SSA to conduct more childhood CDRs.

Introduction

The Supplemental Security Income (SSI) program provides means-tested cash transfers to children with disabilities in the United States. In December 2013, over 1.3 million children received payments averaging $631 per month (Social Security Administration [SSA] 2014b, Tables 4 and 5). As part of its program-integrity efforts, SSA periodically conducts continuing disability reviews (CDRs) to determine the ongoing medical eligibility of SSI recipients. Among the reviews conducted in fiscal year 2009—of which at least 98 percent have now had a final decision rendered after all appeals—SSA ceased eligibility in 47 percent of low birth weight (LBW) child CDR cases, 15 percent of non-LBW child CDR cases, and 37 percent of age-18 redeterminations (SSA 2014a).

This note supplements previous work on the return of adults to SSI participation after exiting the program because of a finding of medical improvement in either a CDR (Hemmeter and Stegman 2013) or an age-18 redetermination (Hemmeter and Gilby 2009) by presenting similar statistics for SSI child participants. Even though CDRs may result in program exits, many child SSI recipients experience long tenures in the program. This outcome is not surprising, as many childhood impairments are life-long and many of them deteriorate over time. Davies, Rupp, and Wittenburg (2009), for example, showed that almost 40 percent of children who were awarded SSI payments at age 13 in 1997 were still receiving payments at age 24.

In our prior work, we estimated that 30 percent of disabled adult SSI recipients who left the program returned to the SSI rolls within 8 years (Hemmeter and Stegman 2013).¹ Whether children face similar prospects of program return is unclear. The significant gaps in services between childhood and adulthood (Government Accountability Office 2012) could result in higher levels of program return; conversely, younger individuals are likely to have more opportunities for self-sufficiency than adults have, possibly resulting in lower levels of program return. In fact, our estimates reveal substantially lower SSI return rates for former child recipients than for adults.

Child CDR Policy

SSA must conduct CDRs for minors at intervals that are determined by the type of case. The agency is statutorily required to conduct (or “release”) LBW child CDRs within 1 year of birth, or later if the impairment is not expected to improve within 12 months. SSA also conducts age-18 redeterminations of SSI eligibility under the program's adult definition of disability, generally within 2 years of the recipient turning 18 (SSA 2011). Cases for non-LBW SSI children, on the other hand, are released for CDRs according to the “diary date” and available funding. The diary date is set at the time of award (or last favorable decision), and is based on whether SSA determines that medical improvement is expected (MIE), possible (MIP), or not expected (MINE). This designation determines when the review date will be scheduled, ranging from 6 months to 7 years after the favorable decision. Once a diary comes due for a child SSI recipient, SSA directly releases the case for a CDR.²

During a CDR, examiners use a medical improvement review standard (MIRS) to determine if an individual continues to meet the program eligibility rules. The MIRS requires examiners to look for medical improvement in the impairment on which eligibility was based since the last favorable decision.³ Examiners use the MIRS except in instances of fraud or failure to cooperate during the CDR process, and in cases in which either an error was clearly made during the last review (initial award or prior CDR) or advances in diagnostic techniques indicate that the impairment is not as disabling as originally determined. Age-18 redeterminations are not subject to the MIRS;⁴ rather, they are treated as new disability determinations using the five-step adult determination process instead of the three-step process used for children.⁵

The number of CDRs that SSA can process depends heavily on agency funding, competing workloads (such as initial claims), and adjudicative capacity at the initial, reconsideration, and hearing levels. Some of SSA's funding is designated specifically for program integrity, of which CDRs are a part. Because funding levels generally do not allow the agency to conduct all of the CDRs scheduled in a given year, SSA prioritizes cases. As a result, in many years, SSA conducted fewer non-LBW child CDRs than it would have with full funding; however, additional dedicated funding in recent years has enabled SSA to conduct those CDRs in increasing numbers.

Data and Methodology

Our primary data source for this analysis is SSA's CDR Waterfall File, which contains detailed information on centrally initiated CDRs with a Disability Determination Service decision. We select the 1998–2008 cohorts of LBW and non-LBW child CDRs and of age-18 redeterminations from that file. In addition to the Waterfall File, we use SSA's Numerical Identification (Numident) file (for dates of death) and the Supplemental Security Record (to replace any missing dates of birth). For data on successful postcessation applications to SSI or to Social Security Disability Insurance (DI) as a disabled worker—each of which we refer to, for brevity, as a “program return” in this note—we use SSA's Disability Research File. Using these data, we estimate the number of program returns through 2012.

Our study population excludes cases from the profile sample;⁶ cases with a missing final-decision date or with inconsistent dates in the data (for example, the final CDR decision date precedes the initial CDR decision date, or date of death precedes the final CDR decision date); and cases either in the appeal process or with time left to appeal. Our final populations consist of 104,031 LBW child CDRs; 992,362 non-LBW child CDRs; and 579,325 age-18 redeterminations.

We present the numbers and percentage distributions of all children and youths who received a CDR or an age-18 redetermination, and of those whose eligibility ceased as a result. We also present the percentages estimated to return to the rolls within 10 years. For LBW child CDRs, we estimate the percentage returning to SSI only. For non-LBW child CDRs, we also present the percentage of former recipients estimated to return to SSI before age 18. All statistics are shown by selected personal and programmatic characteristics. In estimating program return rates, we measure from the date of the final CDR decision to the date the successful application was filed.⁷

Our program-return estimates are based on cumulative incidence functions, which account for censored follow-up periods (that is, different follow-up periods depending on when the CDR decision occurred) and the competing outcome of death.⁸ See Hemmeter and Stegman (2013) for more information on this methodology.

Population Characteristics, Cessation Rates, and Return Rates

In this section, we present the numbers and percentage distributions of children and youths who received a CDR or age-18 redetermination, the resulting cessation rates, and the estimated percentages that returned to SSA's disability programs, all by selected characteristics.

LBW Child CDRs

Table 1 shows that majorities of LBW child SSI recipients received their CDRs at ages 1–2 (77.3 percent) and were assigned the MIP diary type (63.0 percent).⁹ Less than 6 percent of LBW children received a CDR after age 4, and the current review was not the first CDR in about 49 percent of those cases (not shown). About three-quarters of these LBW children entered the SSI program at the initial-application level of adjudication, and a consultative examination was requested during the CDR for slightly less than half of these children.¹⁰

SSA ceased SSI eligibility for about 48 percent of the LBW children in our population, although the cessation rate varies to some degree according to certain characteristics. For example, we see relatively lower cessation rates for children who received a CDR when younger than age 1 and older than age 4; for those who entered the program through a decision at the reconsideration level or higher; and for those who had had a prior CDR. The cessation rate declined annually for CDRs decided over the first half of the study period, from 53.1 percent in 1998 to 43.9 percent by 2004. For CDRs decided after 2004, the cessation rate increased slightly, approaching 50 percent by 2007.

We estimate that within 10 years, 9.4 percent of former LBW child recipients returned to SSI. Chart 1 shows that the rate of return was gradual over our 10-year follow-up period, with about half of the successful reapplicants returning within 4 years of cessation. Table 1 shows relatively lower return rates for LBW children whose CDRs were decided when they were younger than age 1 (6.4 percent) and for those who entered the program at the administrative law judge (ALJ) level or higher (3.0 percent). The latter result may simply reflect the relative rarity of LBW children entering the program at that level and then having their payments ceased because of medical improvement.

The declining return rate in more recent CDR years is largely a mechanical artifact of the data, given the shorter follow-up period for those with cessations in later years. However, in Chart 2, we see somewhat lower return rates for the 1998 and 1999 CDR cohorts in almost every year after the decision than we see for later cohorts. We also see higher return rates for the 2001 and 2002 CDR cohorts, reflecting the last years in our data for which SSA received supplemental funding to reduce the CDR backlog (see Hemmeter and Bailey 2013).

Non-LBW Child CDRs

About 81 percent of the non-LBW child SSI recipients receiving a CDR during 1998–2008 were originally assigned the MIP diary type (Table 2). Among age groups, most CDRs were decided for children aged 5–12, and the second-largest proportion was decided for those aged 13–17.¹¹ Mental disorders are highly prevalent among the general non-LBW SSI children's population; similarly, intellectual disabilities and “other mental disorders” together accounted for 60 percent of the primary impairments in our study population. We also find that about nine out of ten non-LBW child CDR cases had been awarded payments at the initial application level, and almost three-quarters had not undergone a prior CDR.

The overall cessation rate (after appeals) for non-LBW child CDRs was 18.3 percent. The childhood CDR cessation rate was higher for those for whom SSA expected medical improvement (28.4 percent) than it was for those whose medical improvement was considered possible (16.2 percent) or was not expected (8.0 percent). Of the non-LBW child CDR age groups, the youngest (younger than 5) and oldest (18) had the highest cessation rates (26.2 percent and 36.5 percent, respectively); among diagnosis types, the highest cessation rates were for those with neoplasms (54.0 percent), respiratory system diseases (48.1 percent), circulatory system diseases (32.6 percent), and digestive system diseases (33.0 percent).

We estimate that 13.4 percent of non-LBW children returned to SSI and 1.1 percent had become DI disabled-worker beneficiaries within 10 years of a CDR cessation decision (Table 2 and Chart 3a).¹² Because the estimates show that 13.6 percent returned to either program, many children who went on to qualify for DI benefits were actually concurrent DI and SSI beneficiaries. For brevity, we focus on return to SSI, noting that the results for each program are similar in relative importance, if not in magnitude. CDR cases for children who were deemed the least likely to medically improve (the MINE diary type) have a higher estimated return rate (28.3 percent) than do those in the other diary categories (12.4–13.7 percent). The variation in program return rates by age at CDR decision and by years in the program is less pronounced. Former non-LBW child recipients with intellectual disabilities, nervous system and sense organ diseases, and genitourinary system diseases show somewhat higher estimated rates of return (17–21 percent) than do those with other impairments.

We estimate that about 10 percent of children with CDR cessation decisions returned to SSI before age 18 (Table 2 and Chart 3b). The rankings among the various characteristics for program-return percentages by age 18 are similar to those for program return within 10 years. Across CDR cohorts, the range of return rates within a given year since the cessation decision is wider for return by age 18 than it is for return within 10 years (Charts 4a and 4b). For example, for a pre-age-18 program return occurring within 7 years of a final CDR decision, the greatest difference between any two cohorts (2002 and 2005) is 4.5 percentage points (Chart 4b); yet for program return within 10 years, the widest range at this point is 3.2 percentage points (between the 2000 and 2002 cohorts, Chart 4a). In this instance, however, a trend related to supplemental funding for CDRs is not apparent.

Age-18 Redeterminations

More than three-quarters of the age-18 redetermination cases in our study had been assigned the MIP diary type (Table 3). As expected, most (82.2 percent) of the redeterminations were decided when the recipient was aged 18, but the other 17.8 percent were not decided until after the individual turned 19, consistent with findings of SSA's Office of the Inspector General (SSA 2011). As might be expected for program participants who had reached age 18, durations of participation were typically longer than were those for the two types of childhood CDRs covered in this note. About 68 percent of redetermination cases involved youths who had been in the program for 6 or more years, and only 6.1 percent involved youths who had been in for less than 2 years. The most common primary diagnoses were intellectual disabilities (42.9 percent) and “other mental disorders” (30.5 percent). Very few age-18 redetermination cases had proceeded beyond the initial level in the original application process (7.2 percent), although the adjudication level is unknown for 12.5 percent of cases. Less than half of the age-18 redetermination cases had undergone a prior CDR; in a majority of cases, SSA requested a consultative examination.

SSA ceased eligibility in about 34 percent of age-18 redeterminations, which is notably higher than the cessation rates for our populations of LBW and non-LBW childhood CDRs, but is consistent with other studies of redeterminations (for example, Hemmeter and Gilby 2009). The cessation rate varied greatly by diary type, with almost half of MIE cases resulting in cessation compared with only 13.7 percent of MINE cases. Although medical improvement is not considered during the age-18 redetermination, that outcome is not surprising because the MIE cases are deemed more likely to improve (and MINE cases are deemed less likely to) based on the last favorable review by a disability examiner. Thus, one might reasonably expect that MIE cases are less likely than MINE cases to meet the adult definition of disability, all else equal. The cessation rate also appears to be slightly higher for youths whose redeterminations took place after age 18 than it is for those who were 18 at the time of decision. SSI recipients who had been in the program for less than 2 years at the time of their redetermination had a much lower cessation rate (18.2 percent) than did those with longer program durations. Across diagnosis categories, the cessation rates were highest for recipients with respiratory system diseases (72.3 percent), neoplasms (53.3 percent), and “other mental disorders” (50.7 percent) and were lowest for those with diseases of the nervous system and sense organs (12.6 percent). We find that the cessation rate increased with the level of adjudication for the initial award, with a 21.3 percentage point difference in the cessation rate between initial-application awardees and those who were awarded at the ALJ level or higher; however, the 12.5 percent of age-18 redeterminations with an unknown level of initial adjudication had the lowest rate of cessation (22.3 percent).

As one might expect, among SSI recipients whose eligibility was ceased in an age-18 redetermination and who returned to program participation within 10 years, more reentered SSI (14.4 percent) than entered DI as disabled-worker beneficiaries (5.0 percent, Table 3 and Chart 5). We estimate that most of the individuals who entered DI after an age-18 redetermination cessation actually returned to SSI as well (as evidenced by the small differences between the either-program and SSI return rates), implying that they were concurrent DI and SSI beneficiaries. As we did in discussing the findings for the childhood CDR populations, we focus here on return to SSI. We estimate relatively higher return rates for former recipients with the MINE diary type, without a prior CDR, and with shorter program participation periods. Although 22.0 percent of those who were in the program for less than 2 years returned, only 13.0 percent of those who participated for 6 or more years returned to SSI within 10 years. Among primary diagnoses, those with relatively higher estimated return rates—ranging between 21.0 percent and 32.6 percent—were schizophrenia and other psychotic disorders; diseases of the endocrine, nutritional, and metabolic system; and genitourinary system diseases.

Across redetermination cohorts, SSI program return peaked for the 1999 cohort (19.7 percent); however, Chart 6 shows that the estimated SSI return rate for many of the cohorts apparently has not leveled off, suggesting that return rates are likely to continue to increase in later years. This outcome contrasts with that shown in Charts 1–4b for LBW and non-LBW child CDR cases, in which the program-return trajectories appear more concave over time.

Conclusion

In this note, we present statistics on the characteristics of SSI recipients who undergo childhood CDRs (with LBW and non-LBW children considered separately) and age-18 redeterminations. We also present statistics on the outcomes of those reviews and on estimated program return rates of youths for up to 10 years after a cessation decision. We note differences in program-return trends between yearly cohorts across the three groups, particularly for the age-18 redetermination group. Although we do not explore possible reasons for those differences, or the differences in return rates across certain characteristics, we hope our findings will inform the discussion about the SSI program for children and its impact on participants' lives. Future research could explore whether the different post-CDR outcomes are the result of population differences, changes in CDR policy, changes in the availability of resources with which SSA conducts CDRs, or other causes. Additionally, the need, availability, and coordination of services for children and youths exiting SSI merit further exploration.