Based on BostonMedicalCenter model – Barry Zuckerman and Cindy Mann in 1993 – Barry was frustrated that a baby had died from dehydration, because if mom had had some Pedialyte, the death would have been preventable. Cindy was a legal aid lawyer, asked what the law said about this, and they discovered that Medicaid in Massachusetts would cover Pedialyte. Barry decided to add a lawyer to his team, to make sure this never happened again. Cindy is now the Director of the Center for Medicaid and State Operations (CMSO), part of the Centers for Medicare & Medicaid Services (CMS)
FPL is about $5/hr for a family of 1, at 40 hrs/week, about $10/hr for a family of 4, at 40 hrs/week. UVA charity care 0% co-pay for 100% FPL, 70% co-pays for 200% FPL, up to a capped amount, no assistance over 200% FPL.
Connection to statewide network for better connections to local legal aids for patients outside our service area. (Nelson, Fluvanna, Greene, Louisa, Nelson, Charlottesville, Albemarle)Statewide work – ex. utilities turn-off legislation
SSI – Supplemental Security Income. Please stop me if I start talking in alphabet soup that lawyers love so much.
SSI payments are made from general tax funds, not FICAMyth that you must be denied before you get approved. 68.7% of initial applications are denied in Virginia, and about half are denied at the Administrative Law Judge hearing. Appropriate medical evidence and appropriate parental expectations could change these numbers.23,598 kids on SSI in Virginia in 2009 – 82 in Charlottesville, 122 in Albemarle County. (From SSA)1,826,179 kids in Virginia in 2008, so it’s a small percentage – 1.29%
Doctors don’t need to look at the financial criteria – SSA does a pretty good job with that. It’s the medical determination that is most often problematic for applicants.
For kids, a percentage of the parents’ income is deemed, or counted as their income. The system is built to allow people to try to work, but not to be independently wealthy and collecting SSI.
Medicaid can be for kids below 133% FPL, or for kids in a waiver program based on disability. If SSA determines you aren’t disabled, Medicaid follows that determination for 12 months, unless there is new evidence – so the SSI denial can lead to a denial of Medicaid waiver services.
The extra income and Medicaid can improve patient compliance by removing barriers to care. Parents don’t keep their kids in poor housing, or not feed them well, because they want to be bad parents. Sick kids lead to missed work, which leads to income instability for families without paid time off.
Okay, I see the benefit of SSI for my patient. Why can’t I just say “Patient is totally disabled.”
Obscenity test: I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description ["hard-core pornography"]; and perhaps I could never succeed in intelligibly doing so. But I know it when I see it, and the motion picture involved in this case is not that. [Emphasis added.] ” — Justice Potter Stewart, concurring opinion in Jacobellis v. Ohio378 U.S. 184 (1964), regarding possible obscenity in The LoversJustice Stewart later recanted this view in Miller v. California, (1973) in which he accepted that his prior view was simply untenable. Social Security agrees, which is why they define disability so carefully.
3 part test. Child must have a disabling condition, it must cause them functional limitations, and the condition has to be permanent. No broken leg – temporary conditionNo ADHD if the child is succeeding despite that. Myth of ADHD SSI – often a combination of impairments, including ADHD. No SSI for asthma, if child is responding to treatment. Realistic expectations for parents are important.
I get letters from Social Security all the time, and I just send them to the Medical Records Department. Isn’t that appropriate?
SSA asks for information that a treating physician often already knows, and doesn’t list. Do you write “Child has hemophilia, expected to have for life?” in chart? Why would you? Do you go through a list of all things a child should do at that age? Why would you? Answer is NOT to change your charting to add all that material, but to provide that information when it’s needed in a different format.
If you want to prove to SSA that your patient is disabled, you need to give them evidence that they meet a listing, and that they can’t function as well as their peers b/c of it. (There is a standard for the functional limits, and we’ll talk about that later.)
Blue Book listings for a variety of problems, some for adults, some for kids. Kids listings are divided into 14 groups. Growth ImpairmentMusculoskeletal SystemSpecial Senses and SpeechRespiratory SystemCardiovascular SystemDigestive SystemGenitourinary ImpairmentsHematological Disorders Skin DisordersEndocrine SystemImpairments that Affect Multiple Body SystemsNeurologicalMental DisordersMalignant Neoplastic DiseasesImmune System Disorders
From the Social Security Administration . The role of the MLP attorney is to translate from legalese to English, and medical jargon to English.
Sometimes, a child is disabled not because they meet any specific listing, but because the total of all their impairments “adds up” to the equivalent of a listing.
Consultative Exams are used when patient doesn’t have a treating source, or when the records don’t have enough information. CEs are not always helpful for patients, because it depends on a snapshot, rather than a longitudinal view. CE’s are often very quick, and are usually least helpful when trying to measure a patient’s pain level or mental health.
SSA specifically doesn’t want the doctor to decide if the child is disabled, but does want to know what they can do compared to other kids, so they can decide if the child is disabled. Consider yourself an “expert witness,” but via paper, not a courtroom.
This is all the stuff in the medical records. Finally – something that you already do!
You thought you knew what asthma was, and when it was disabling. Here’s what Social Security has to say about it.
Writing a letter can be a more effective way to show SSA your patient meets the standard, without spending a ton of time on this.
If you have this test, and the patient meets it, you can stop here.
Here’s the table that SSA looks at.
Or keep reading to see which criteria your patient meets.
And write the letter to show this.
It’s much easier to write a letter when you know what SSA is looking for. Have any of you put the birth parents’ heights in the chart for your asthma patients?
Disability is based on both meeting the listing, and the inability to function successfully because of the disability.
This is something that often is NOT in the clinical notes.
In each area or domain of functioning, there is a list of things to evaluate.
This degree of limitation may arise when several activities or functions are limited, or when only one area is limited as long as the degree of limitation is such as to interfere seriously with the child’s functioning
Included in your packet is a checklist you can use with any of your patients who are applying for SSI.
Like Maslow’s hierarchy of needs – families that are stressed can only worry about so much. While this makes intuitive sense, it was also demonstrated in a study:Racial/Ethnic Variation in Parent Perceptions of AsthmaVolume 8, Issue 2, Pages 89-97 (17 March 2008) Academic PediatricsBlack and Latino children with asthma have worse morbidity and receive less controller medication than their white peers. Scant information exists on racial/ethnic differences in parent perceptions of asthma. To compare parent perceptions among black, Latino, and white children with asthma in 4 domains: (1) expectations for functioning with asthma; (2) concerns about medications; (3) interactions with providers; and (4) competing family priorities.Of the 739 study children, 24% were black, 21% Latino, and 43% white. Parents of black and Latino children had lower expectations for their children's functioning with asthma (P < .001), higher levels of worry about their children's asthma (P < .001), and more competing family priorities (P = .004) compared with parents of white children. Parents of Latino children had higher levels of concern about medications for asthma than parents of black or white children (P = .002). There were no differences among racial/ethnic groups in reports of interactions with the provider of their children's asthma care.Efforts to eliminate disparities in childhood asthma may need to address variation in expectations and competing priorities between minority and white families.
Even though all of you are time crunched, the time to write a letter will lead to better health outcomes for your patient.
Doctor participation earlier leads to earlier benefits, earlier access to Medicaid, earlier patient compliance. Example – mom of 4yo with hemophilia. Working poor, no access to health insurance, but the SSI benefits mean she can work and get insurance coverage for her son.
Really, if you can master this, surely you can overcome a little red tape to help your clients.
Look at this as an investment of your time…. Both for this patient, and future patients.
Why does this help you? Help patients earlier in the process. SSA pays back benefits, but that doesn’t help kids now. Why does this help me? Fewer cases that need a lawyer – more people served.
Cell phone for medical providers, not patients!
Carolyn Pointer, JDDecember 9, 2010The Betty Sams ChristianChild Health Advocacy Programat the UVA Medical CenterMedical Legal Partnerships| Charlottesville
Neither my husband nor I havea personal or professionalfinancial relationship orinterest in any proprietaryentity producing healthcaregoods or services.December 9, 2010MLP|Charlottesville
A medical-legal collaboration addresses themultiple needs of low-income patients Changes legal aid to a preventive model◦ Provider training on legal issues, how they affecthealth, and how to identify them.◦ Advice, counsel, and extended representation forpatients and families in need◦ Curbside consults for providers◦ An attorney becomes part of the health care teamDecember 9, 2010MLP|Charlottesville
100% 125% 200%Family of 1 10,830 13,538 21,660Family of 2 14,570 18,213 29,140Family of 3 18,310 22,888 36,620Family of 4 22,050 27,563 44,100 Legal Aid – 125%, some exceptions to 200% SNAP (Food Stamps) – usually 130% FPL WIC – 185% FPL FAMIS (SCHIP) for children/PW– 200% Medicaid (FAMIS Plus) for children/PW– 133%December 9, 2010MLP|Charlottesville
UVA Pediatric Primary Care & Specialty Clinics UVA Newborn Nursery Kluge Children’s Hospital UVA Pediatrics at Orange UVA Northridge Pediatrics UVA NICU Blue Ridge CareConnection for ChildrenDecember 9, 2010MLP|Charlottesville
Understand therelationshipbetween SSI,Medicaid, andpatientcompliance forchildren withdisabilities. Understand thephysicians role inprovidinginformation toSocial Security tohelp with disabilitydetermination.December 9, 2010MLP|Charlottesville
And what does it have to dowith patient compliance orMedicaid?December 9, 2010MLP|Charlottesville
Run by Social Security Paid for by general taxes SSI makes monthlypayments (up to $674) tohelp low income, aged,blind, ordisabled/chronically illpeople with limitedresources. Must be legally presentin the United States,immigrant eligibilityrestricted.December 9, 2010MLP|Charlottesville
Medical Criteria Financial Criteria Physical or mentalcondition(s) that veryseriously limits his orher activities Condition lasts 1 year+or results in death Low resources ($3,000for a couple, excludesthings like your homeand vehicle) Low income (part ofparents’ income countsfor most children.)December 9, 2010MLP|Charlottesville
Family Category Income LimitIndividual whose income is only from wages $1433Individual whose income is not from wages $694Couple whose income is only from wages $2,107Couple whose income is not from wages $1,031*The larger your income, the lower your monthly SSI payment.Income subject to deductions, and, in some cases, to deeming rules.Maximum Monthly SSI payment:$674/individual, or $1,011/coupleDecember 9, 2010MLP|Charlottesville
While not automatic, almost all childrenreceiving SSI also are eligible for Medicaid.◦ The Virginia Medicaid resource test is stricter thanthe SSI resource test. Medicaid provides comprehensive healthinsurance, prescription drug coverage, andtransportation to appointments. If SSA says you are NOT disabled, Medicaidfollows that determination for 12 months.December 9, 2010MLP|Charlottesville
So why doesn’t Social Securitylisten when I tell them mypatient is totally disabled?December 9, 2010MLP|Charlottesville
December 9, 2010MLP|CharlottesvilleMedical school, internship,residency, fellowship…I’ve been a pediatrician for15 years. I know what adisabled child looks like.
A medically determinable physical or mentalimpairment or combination of impairmentsthat causes marked and severe functional limitations, andthat can be expected to cause death or that has lasted orcan be expected to last for a continuousperiod of not less than 12 months.December 9, 2010MLP|Charlottesville
TimeCrunchLots ofPaperworkSSI requests aresent to MedicalRecords.December 9, 2010MLP|Charlottesville
Do you list medical evidence for eachdiagnosis?◦ Example - FEV1 test for asthma Do you list functional impairments?◦ Example - Ability to dress without assistance Do you list the likely duration of diagnosis? Should this be in the Medical Record?December 9, 2010MLP|Charlottesville
Evidence of Impairment Functional AssessmentDecember 9, 2010MLP|Charlottesville
To be “disabled,” a child must meet a listingin “The Blue Book.”http://www.ssa.gov/disability/professionals/bluebook/ChildhoodListings.htm Or… the child must have a variety ofdocumented problems that total up to be theequivalent of a listing.December 9, 2010MLP|Charlottesville
A medically determinable physical or mentalimpairment is an impairment that resultsfrom anatomical, physiological, orpsychological abnormalities which can beshown by medically acceptable clinical andlaboratory diagnostic techniques. A physicalor mental impairment must be established bymedical evidence consisting of signs,symptoms, and laboratory findings-not onlyby the individuals statement of symptoms.December 9, 2010MLP|Charlottesville
An anatomical, physiological, orpsychological abnormality Backed up by medical evidence (x-rays, labs, clinical notes) from atreating source That meets the “listing” in the SocialSecurity Administration’s Blue BookDecember 9, 2010MLP|Charlottesville
A doctor or psychologist who has a ongoingpatient relationship Or who had an ongoing patient relationshipin the past. Not someone seen for a “CE” (ConsultativeExaminations)December 9, 2010MLP|Charlottesville
The treating source is neither asked norexpected to decide whether the claimant isdisabled. However, a treating source will usually beasked to provide a statement about a child’sfunctional limitations compared to childrenthe same age who do not have impairments.December 9, 2010MLP|Charlottesville
medical history; clinical findings (such as the results ofphysical or mental status examinations); laboratory findings (such as blood pressure,x-rays); diagnosis; treatment prescribed with response andprognosis.December 9, 2010MLP|Charlottesville
103.03 Asthma. With: A. FEV1 equal to or less than the value specified in Table Iof 103.02A: or B. Attacks (as defined in 3.00C), in spite of prescribed treatment andrequiring physician intervention, occurring at least once every 2 monthsor at least six times a year. Each inpatient hospitalization for longer than24 hours for control of asthma counts as two attacks, and an evaluationperiod of at least 12 consecutive months must be used to determine thefrequency of attacks. or C. Persistent low-grade wheezing between acute attacks or absence ofextended symptom-free periods requiring daytime and nocturnal use ofsympathomimetic bronchodilators with one of the following: 1. Persistent prolonged expiration with radiographic or other appropriateimaging techniques evidence of pulmonary hyperinflation orperibronchial disease; or 2. Short courses of corticosteroids that average more than 5 days permonth for at least 3 months during a 12-month period; or D. Growth impairment as described under the criteria in 100.00.December 9, 2010MLP|Charlottesville
A. FEV1 equal to or less than the valuespecified in Table Iof 103.02A: ORDecember 9, 2010MLP|Charlottesville
B. Attacks (as defined in 3.00C), in spite ofprescribed treatment and requiringphysician intervention, occurring at leastonce every 2 months or at least six times ayear. Each inpatient hospitalization forlonger than 24 hours for control of asthmacounts as two attacks, and an evaluationperiod of at least 12 consecutive monthsmust be used to determine the frequency ofattacks. ORDecember 9, 2010MLP|Charlottesville
C. Persistent low-grade wheezing betweenacute attacks or absence of extendedsymptom-free periods requiring daytimeand nocturnal use of sympathomimeticbronchodilators with one of the following:◦ 1. Persistent prolonged expiration withradiographic or other appropriate imagingtechniques evidence of pulmonary hyperinflationor peribronchial disease; or◦ 2. Short courses of corticosteroids that averagemore than 5 days per month for at least 3months during a 12-month period; ORDecember 9, 2010MLP|Charlottesville
D. Growth impairment as described underthe criteria in 100.00.December 9, 2010MLP|Charlottesville
I began treating Name, DOB xx/xx/xxxx, onxx/xx/xxxx. My patient was diagnosed withasthma on xx/xx/xxxx. His/ Her asthmacauses marked and severe functionallimitations, that has lasted or can beexpected to last for a continuous period ofnot less than 12 months. Below is the clinicalevidence for my assessment:December 9, 2010MLP|Charlottesville
I began treating Jose Doe, DOB 09/27/2004,on 09/30/2004. My patient was diagnosedwith asthma on 11/2/07. His asthma causesmarked and severe functional limitations, thathas lasted since 2008, without interruption.Below is the clinical evidence for myassessment:December 9, 2010MLP|Charlottesville
On date, Name had a FEV1 of ____ (must beequal to or less than the value specified inTable I). Name’s height (without shoes) wasxx centimeters on that date.On 9/26/2010, Jose had a FEV1 of .65. Jose’sheight (without shoes) was 128 centimeterson that date.December 9, 2010MLP|Charlottesville
In spite of prescribed treatment, Name has hadasthma attacks (Persistent low-grade wheezingbetween acute attacks or absence of extendedsymptom-free periods requiring daytime andnocturnal use of sympathomimetic bronchodilators)requiring physician intervention, occurring at leastonce every 2 months or at least six times a year.Each inpatient hospitalization for longer than 24hours for control of asthma counts as two attacks,and an evaluation period of at least 12 consecutivemonths must be used to determine the frequency ofattacks. In the past 12 months, Name requiredphysician intervention on these dates: _________, andwas hospitalized for more than 24 hours on thesedates: _______________.December 9, 2010MLP|Charlottesville
Name has Persistent low-grade wheezing betweenacute attacks or absence of extended symptom-freeperiods requiring daytime and nocturnal use ofsympathomimetic bronchodilators with one of thefollowing: Persistent prolonged expiration with radiographic orother appropriate imaging techniques evidence ofpulmonary hyperinflation or peribronchial disease.(List date range of persistent prolonged expirationand date and outcome of radiographic or otherappropriate imaging techniques.) Short courses of corticosteroids that average morethan 5 days per month for at least 3 months during a12-month period on these dates: _______________.December 9, 2010MLP|Charlottesville
Option D. Growth impairment as described under the criteria in100.00. Description of growth impairment: _________ A. Impairment of growth may be disabling in itself or it may bean indicator of the severity of the impairment due to a specificdisease process. Determinations of growth impairment should bebased upon the comparison of current height with at least threeprevious determinations, including length at birth, if available.Heights (or lengths) should be plotted on a standard growthchart, such as derived from the National Center for HealthStatistics: NCHS Growth Charts. Height should be measuredwithout shoes. Body weight corresponding to the agesrepresented by the heights should be furnished. The adultheights of the childs natural parents and the heights and ages ofsiblings should also be furnished. This will provide a basis uponwhich to identify those children whose short stature represents afamilial characteristic rather than a result of disease. This isparticularly true for adjudication under 100.02B.December 9, 2010MLP|Charlottesville
a statement about what the claimant can stilldo despite his or her impairment(s) if the claimant is a child under age 18, thisstatement should describe the child’sfunctional limitations (compared to peers) in◦ acquiring and using information,◦ attending and completing tasks,◦ interacting and relating with others,◦ moving about and manipulating objects,◦ caring for yourself, and◦ health and physical well-being.December 9, 2010MLP|Charlottesville
Based upon your clinical evaluation and/ordirect observation, considering all of thechild’s mental and physical impairments,please specify the degree of functionallimitation in the child’s ability to perform thebelow activities, at a level appropriate tounimpaired children of the same age as thischild.December 9, 2010MLP|Charlottesville
Areas to evaluate Example Cognition/communication Motor Social Personal Concentration,persistence, or pace Gross motor skillsused for walking,skipping, jumping,running, throwing,catching.Degree of limitation mild or no limit moderately limited seriously limited extremely limitedDecember 9, 2010MLP|Charlottesville
Social Security refers to a “marked limitation.” For children aged 3 to 18, this means morethan moderate and less than extreme.◦ Where standardized tests measure the ability, atleast two standard deviations below the norm For children from birth to age 3, functioningat no more than two-thirds of chronologicalage meets this level.December 9, 2010MLP|Charlottesville
In children aged 3 to 18, it means nomeaningful function in a given area.◦ Where standardized tests measure the ability, atleast three standard deviations below the norm. For children from birth to age 3, functioningat no more than one-half of chronologicalage meets this level.December 9, 2010MLP|Charlottesville
Cognition/communication: Ability to retain and recall information._mild or no limit _moderately limited _seriously limited _extremely limited Ability to solve problems through intuition,perception, verbal or nonverbal reasoning._mild or no limit _moderately limited _seriously limited _extremely limitedA checklist is included in your packet for quicker functionalevaluations for your patients applying for SSI.December 9, 2010MLP|Charlottesville
Why is SSI important? What Should I Do? SSI provides income forfamilies withchronically ill children Access to Medicaid Patient compliancebecomes possible When a patient isapplying for SSI, fill outthe functionalchecklist. When a patient isapplying for SSI, fill outa form letter if theymeet criteria. If not, call the MLP foradvice.December 9, 2010MLP|Charlottesville
December 9, 2010MLP|CharlottesvilleAnyone who can learn the Krebs cycle canlearn how to be a child advocate.- Jerome A. Paulson
Access appropriate services for patient Minimize time needed for advocacy Develop good relationships with communitypartners
When you aren’t sure what to do, call yourMLP attorney and ask. When you’re not sure what to write, call yourMLP attorney and ask. When you aren’t sure if this is a case, callyour MLP attorney and ask.December 9, 2010MLP|Charlottesville