TN 1 (04-00)
DI 28005.030 The CDR Evaluation Process - Title XVI Child - Step-by-Step Discussion
A. Introduction
The discussion in subsection DI 28005.030C. numbered to correspond to the numbered steps in DI 28005.020 and the summary chart in DI 28005.025.
B. Policy - Things To Keep In Mind
1. For Title XVI Disability Purposes, A Child is Anyone Under Age 18
For disability purposes, “Adult means a person who is age 18 or older. Child means a person who has not attained age 18” (Section 416.902).
For other title XVI purposes, e.g., income and resources, some individuals age 18 or older are considered children (“DCs” ), and some individuals under age 18 are considered adults (“DIs”), but these categorizations have no bearing on whether an individual is a child or an adult for disability purposes.
2. For Title XVI Children, “Equals” Includes Medical and Functional Equals
As regards title XVI children, wherever the term “equals” (and related terms, e.g., “equaled”) appears without “medically” or “functionally” as a modifier, it includes both of those concepts.
For example “Does Your Impairment(s) Still Meet or Equal the Severity of the Listed Impairment That it Met or Equaled Before?” must be read as “Does Your Impairment(s) Still Meet or Medically or Functionally Equal the Severity of the Listed Impairment That it Met or Medically or Functionally Equaled Before?”
REMINDER: The basis for determining functional equivalence changed effective January 2, 2001. Prior to that date, the basis was functionally equaling a listed impairment. On or after that date, the basis was functionally equaling the listings.
3. Some Group I Exceptions Do Not Apply to Title XVI Children
P.L. 104-193, enacted August 22, 1996, changed the MIRS exceptions that apply to title XVI children. The “Advances in Medical or Vocational Therapy or Technology” and “Vocational Therapy” exceptions, applicable to title II and adult title XVI beneficiaries, no longer apply to title XVI children.
4. 1619 Provisions Apply
SGA is not a reason for disability cessation for title XVI children because of the 1619 provisions (see DI 28005.015B.)
C. Procedure
1. Has there been MI?
Determine whether there has been MI in any impairment(s) the child had at the time of the CPD (DI 28010.010).
If “NO” (no MI) find that disability continues, UNLESS a Group I or Group II exception applies (see DI 28020.001).
If a Group I exception applies, go to step 3.
If a Group II exception applies (see DI 28020.900), find that disability has ended. Group II exceptions may apply at any point in the CDR process.
If “YES” (MI has occurred), go to step 2.
2. Does Impairment(s) Meet/Equal Severity of Listing it Met/Equaled Before?
If there has been MI, consider whether the impairment(s) that we considered at the CPD still meets or equals the severity of the listing it met or equaled at that time. Consider the current severity of that impairment(s), and the same listing section used to make that determination or decision as it was written at that time, even if it has since been revised or removed from the Listing of Impairments. For listings with different criteria for different ages, use the criteria applicable to the age of the child at the time of the CDR.
If “YES” (impairment(s) still meets or equals listing it met or equaled before), find that disability continues, UNLESS a Group I or Group II exception applies (see DI 28020.001).
If a Group I exception applies, go to step 3.
If a Group II exception applies (see DI 28020.900), find that disability has ended. Group II exceptions may apply at any point in the CDR process.
If “NO” (impairment(s) does not still meet or equal listing it met or equaled before), go to step 3.
NOTE: See Social Security Ruling (SSR) 05-03p (in DI 28005.021) for how we apply the functional equivalence rules at this step, and how we apply this step when the CPD was based on functional equivalence to the listings.
3. Is the Child Currently Disabled?
If there has been MI, and the impairment(s) no longer meets or equals the severity of the listing it met or equaled at the time of the CPD, or if a Group I exception applies, consider whether the child is currently disabled under the rules in DI 25220.010 and DI 25225.001, taking into account all factors relevant to assessing impairment severity -- e.g., basic consideration (DI 25210.001 through DI 25210.040) and pain and other symptoms (DI 24501.021). Consider all impairment(s) the child now has, including any not considered at the time of the CPD. The steps in determining current disability are summarized as follows:
Is current impairment(s) severe? (DI 25220.005)
If “NO” (impairment(s) is not severe), find that disability has ended.
If “YES” (impairment(s) is severe), go to b.
Does current impairment(s) meet or medically equal the severity of any current listing? (DI 25220.010)
If “YES” (impairment(s) meet or medically equal the severity of a current listing), find that disability continues.
If “NO” (impairment(s) does not meet or medically equal the severity of a current listing) go to c.
Does current impairment(s) functionally equal the listings? (DI 25225.001)
If “YES” (impairment(s) functionally equals the listings), find that disability continues.
If “NO” (impairment(s) does not functionally equal the listings), find that disability has ended.
4. Complete SSA-538
Explain the CDR determination on an SSA-538 (see DI 25230.001).
a. Section I
In I.A., when listing all established impairments, indicate which, if any, are new or for any other reason not considered in the CPD.
If the child's current impairment(s) is found to meet, or medically or functionally equal the severity of a current listing, check block B.2., B.3., or B.4. as appropriate.
For all other CDR outcomes, check block B.7. and provide a very brief explanation in the space provided (e.g., “Meets old listing,” “MI; not currently disabled” ). (In all such cases, Section III. must also be completed.)
b. Section II.
Complete Section II if functional equivalence is considered at step 2 (“prior listing still met/equaled?”) and/or step 3 (“currently disabled?”).
If step 2 establishes that the CPD impairment(s) does not still meet or medically or functionally equal the CPD listing, Section II of a second SSA-538 may or may not be required at step 3:
Second SSA-538 not required if all current impairments were considered in the CPD. If all current impairments were considered at the time of the CPD, completing Section II of a second SSA-538 is not necessary. This is because the step 2 SSA-538 will have established that the impairment(s) does not currently result in one extreme or two marked limitations, and therefore that it does not functionally equal the listings.
If all current impairments were considered in the CPD, so that only one SSA-538 is needed, clearly mark the SSA-538 “Current impairment(s) same as CPD impairment(s).”
CAUTION: Step 3 must be considered even if step 2 establishes that the impairment(s) does not functionally equal the severity of a listing, because it is sometimes possible for an impairment(s) to meet or medically equal the severity of a current listing even if it does not functionally equal the severity of any listing.
Second SSA-538 required if not all current impairments were considered in the CPD. If not all current impairments were considered at the time of the CPD, completing Section II of a second SSA-538 is necessary, unless the current impairment(s) meets or medically equals the severity of a listing. This is because the step 2 SSA-538 will not have considered all current impairment(s).
If not all current impairment(s) were considered in the CPD, so that functional equivalence must be considered at both step 2 and step 3, clearly mark the two SSA-538s “CPD SSA-538; Considers CPD Impairment(s) Only” and “Current SSA-538; Considers All Impairments.”
c. Section III
Complete section III in all cases except those in which the impairment(s) is found to meet or medically equal the severity of a listing. There is no set format for Section III, but it must provide a clear and straightforward explanation of the CDR determination.