Social Security Act, Section 1614(a)(3)(C); 20 CFR 416.901 - 416.906, 416.924, 416.925 - 416.926a
DI 25201.001 Childhood Disability - Introduction
This chapter provides the policies and procedures for making initial and reconsideration determinations for children (individuals under age 18) who are claiming payments based on disability under the Supplemental Security Income (SSI) program.
The definition of disability for children claiming SSI benefits (see DI 25201.001D.) is found in the Social Security Act (section 1614(a)(3)(C)). That definition, and related childhood disability provisions, were enacted on August 22, 1996 as part of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Public Law (P. L.) 104-193).
On February 11, 1997, we published interim final rules with a request for comments to implement the provisions of P. L. 104-193. In response to the public comments, we issued revised final rules on September 11, 2000. The instructions in chapter DI 25200.000 ff. reflect the revised final rules.
The title XVI definition of disability does not apply to title II claimants, regardless of age.
B. Policy - effective dates – for childhood disability provisions of P. L. 104-193
The childhood disability provisions of P. L. 104-193 were effective August 22, 1996 for all title XVI childhood disability claims that were filed on or after August 22, 1996, and all childhood disability claims that were not finally adjudicated before that date. Interim final rules effectuating these provisions were published on February 11, 1997.
2. Final Adjudication
A claim was not finally adjudicated prior to August 22, 1996 if:
the initial claim is pending on or after that date; or,
the claim was denied in whole (see DI 25201.001B.3.) prior to August 22, 1996 and, on or after that date, there is pending a request for either administrative or judicial review; or,
on or after that date, there is pending readjudication by SSA pursuant to relief in a class action; or,
on or after that date there is pending implementation by SSA of a court remand order.
3. Effect of “Denied in Whole” Language
Per DI 25201.001B.2., a claim denied in whole prior to August 22, 1996, and in which a request for administrative or judicial review is pending on or after that date, is subject to these rules. Therefore, a claim that was denied in part prior to August 22, 1996, and under appeal, is not subject to these rules for the period prior to that date. Claims denied in part include unfavorable onset cases, “closed period” cases, and claims denied in part for nondisability reasons, such as income and resources.
a. Appeals on Unfavorable Onset Cases
If a childhood disability claim adjudicated prior to August 22, 1996 involved a favorable determination, but with an onset later than alleged, and a request for administrative or judicial review involves the onset issue, the prior rules apply in deciding the onset issue for the period prior to August 22, 1996. If the reviewer finds that no onset date can be established prior to August 22, 1996, the current rules apply in deciding the onset issue starting on that date. The prior rules may be found in the April 1, 1996 edition of 20 CFR sections 416.924 - 416.924e.
b. Appeals on “Closed Period” Cases
In general, closed period issues are adjudicated under the medical improvement review standard (MIRS) - See DI 28001.001 ff. However, there are circumstances in which these initial rules are applicable.
If a childhood disability claim adjudicated prior to August 22, 1996 involved a favorable determination, but with a cessation date, and a request for administrative or judicial review involves the cessation issue, the prior MIRS rules apply in deciding the cessation issue for the period prior to August 22, 1996. The prior rules for application of the MIRS may be found in the April 1, 1996 edition of 20 CFR section 416.994a.
If the reviewer finds that no cessation date should be established prior to August 22, 1996, and the allowance determination was based on an individualized functional assessment (IFA) or on consideration of maladaptive behaviors in the paragraph B criteria of any childhood mental disorder listing, P. L. 104-193 requires that the child's eligibility be redetermined under these rules for determining initial eligibility, rather than the MIRS.
C. Policy – effective dates – revised final childhood disability rules
In response to the public comments on the interim final rules, we issued revised final rules on September 11, 2000. Those revised final rules are effective January 2, 2001. The revised final rules apply to:
new applications filed on or after January 2, 2001, and
claims pending at any stage of the administrative review process, including claims pending administrative review after remand from a Federal court, for the entire period at issue.
With respect to claims in which we have made a final decision, and that are pending judicial review in Federal court, we expect that the court's review of the Commissioner's final decision would be made in accordance with the rules in effect at the time of the final decision. If the court determines that the Commissioner's final decision is not supported by substantial evidence, or contains an error of law, we would expect that the court would reverse the final decision, and remand the case for further administrative proceedings pursuant to the fourth sentence of section 205(g) of the Act, except in those few instances where the court determines that it is appropriate to reverse the final decision and award benefits, without remanding the case for further administrative proceedings. In those cases decided by a court after the effective date of the rules, where the court reverses the Commissioner's final decision and remands the case for further administrative proceedings, on remand, we will apply the provisions of these final rules to the entire period at issue in the claim.
D. Policy - definition of disability for children (section 416.906)
If you are under age 18, we will consider you disabled if you have a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months. Notwithstanding the preceding sentence, if you file a new application for benefits and you are engaging in substantial gainful activity we will not consider you disabled. We discuss our rules for determining disability in children who file new applications in DI 25201.005 ff.
E. Definitions (drawn from section 416.902)
The following definitions apply to disability evaluation under title XVI. In regard to the definitions of Adult and Child, note that an individual age 18 or older is an adult for disability evaluation purposes even if the claim type is DC or BC (because the individual is a student), and an individual under age 18 is a child for disability evaluation purposes even if the claim type is DI, BI, DS, or BS (because the individual is married or head of household).
Adult means a person who is age 18 or older.
Child means a person who has not attained age 18.
Commissioner means the Commissioner of Social Security.
4. Disability Redetermination
Disability redetermination means a redetermination of your eligibility based on disability using the rules for new applicants appropriate to your age, except the rules pertaining to performance of substantial gainful activity - see DI 23570.001 ff. For individuals who are working and for whom a disability redetermination is required, we will apply the rules in SI 02302.001 ff. concerning the work incentive provisions of sections 1619(a) and 1619(b) of the Act. In conducting a disability redetermination, we will not use the rules for determining whether disability continues set forth in DI 28005.001 ff.
Impairment(s) means a medically determinable physical or mental impairment or a combination of medically determinable physical or mental impairments.
6. The Listings
The listings means the Listing of Impairments in appendix 1 of subpart P of part 404 of chapter III of Title 20 of the Code of Federal Regulations (CFR). When we refer to an impairment(s) that “meets, medically equals, or functionally equals the listings,” we mean that the impairment(s) meets or medically equals the severity of any listing in appendix 1 of subpart P of part 404 of chapter III of Title 20 of the CFR, as explained in DI 25220.010, or that it functionally equals the severity of the listings, as explained in DI 25225.001 ff.
7. Marked and Severe Functional Limitations
Marked and severe functional limitations, when used as a phrase, means the standard of disability in the Social Security Act for children claiming SSI benefits based on disability and is a level of severity that meets, medically equals, or functionally equals the listings. The words “marked” and “severe” are also separate terms used throughout part 4 of the POMS to describe measures of functional limitations; the term “marked” is also used in the listings. The meaning of the words “marked” and “severe” when used as part of the term marked and severe functional limitations is not the same as the meaning of the separate terms “marked” and “severe” used elsewhere in these rules.
8. We or Us
We or us refers to either the Social Security Administration or the State agency making the disability or blindness determination.
9. You, Your, Me, My and I
You, your, me, my and I mean, as appropriate, the person who applies for benefits, the person for whom an application is filed, or the person who is receiving benefits based on disability or blindness.