Changes in Diagnostic Codes at Age 18
Hemmeter, Jeffrey, Social Security Bulletin
Each year, as tens of thousands of child Supplemental Security Income (SSI) recipients reach age 18, the Social Security Administration (SSA) redetermines their medical eligibility according to adult disability standards. Child participation in the SSI program has grown substantially in recent years, and youth with mental impairments make up an increasing proportion of the program population (SSA 2012a). The growth in the proportion of children with mental impairments among SSI recipients has led to concern among some individuals that too many youth receive SSI.1 As the SSI youth population increases and transitions into adulthood, the potential for long-term program participation increases as well.2 In addition, some have argued that certain mental impairments, such as speech and language delays, are more subjective or time-limited (Burkhauser and Daly 2011), requiring more vigilant oversight by SSA.3 Although SSA conducts continuing disability reviews (CDRs) on SSI recipients, limited funding and resources have led to fewer CDRs being conducted for child SSI recipients than the law requires (GAO 2011). For many child SSI recipients, the age-18 redetermination is the first time their disability is reviewed during their tenure in the program.
The concerns about the number and program tenure of children with mental impairments may be justified if a higher proportion of those children are removed from the program or reclassified with other diagnoses during their age-18 redeterminations. However, the statistics in this note show that, relative to youth with mental disabilities, those with many nonmental disabilities experience similar or higher rates of both program removal and continuation with a different diagnosis at the age-18 redetermination.
SSA standards for CDRs differ from those for age-18 redetermination: CDRs generally require medical improvement since the last favorable decision for a cessation decision, and age-18 redeterminations are treated as a new medical decision based on adult standards (discussed in the next section). Thus, cessations and diagnostic changes at age 18 do not necessarily imply incorrect initial allowances to the program. The outcomes could equally indicate a system that accurately addresses the different needs of children and adults. Nonetheless, it is important to understand how the disabilities of youth who undergo an age-18 redetermination are reclassified. This note provides statistics on those reclassifications, focusing on childhood mental impairments, thus affording a more complete picture of the transition experiences of SSI youth.
The Age-18 Redetermination
SSA redetermines the medical eligibility of each child SSI recipient when he or she attains age 18.4 To remain eligible, the youth must meet the adult standards of disability, which may be more restrictive than the standards for children (although SSA improved the equivalency of disability decision processes for adults and children in the wake of the 1990 Sullivan v. Zebley decision).5 Additionally, for those who do not have a listing-level disability, a child's disability must result in "marked and severe functional limitations," whereas an adult's disability must result in the inability to perform substantial gainful activity.6
The outcome of roughly two-thirds of these redeterminations, after appeals, is program continuation (SSA 2012a). Youth diagnosed with mental impairments other than "intellectual disabilities or schizophrenia" and "psychoses and other neuroses" are among the most likely to receive an initial cessation and the least likely to appeal or return to the program (Hemmeter and Gilby 2009). Roughly 10 percent of youth whose eligibility ceases at age 18 successfully reapply for SSI payments as an adult within 4 years. Readers interested in other aspects of the age-18 redetermination are referred to Rogowski and others (2002), Hemmeter and Gilby (2009), and Hemmeter, Kauff, and Wittenburg (2009). …