Social Security: With You Through Life’s Journey…

Produced at U.S. taxpayer expense

Social Security Beneficiaries

Social Security 57.7 million

Both 2.7 million

SSI 5.5 million

Social Security Disability Insurance (SSDI) The SSDI program pays monthly benefits to you and to certain members of your family if: • You have worked long enough, recently enough, and

• You have a medical condition that has prevented you

from working – or is expected to prevent you from working – at a substantial level for at least 12 months, or your medical condition is expected to end in death.

Supplemental Security Income (SSI) Social Security administers the Supplemental Security Income program, which pays benefits to disabled adults and children who have limited income and resources.

SSI benefits also are payable to adults age 65 and older who do not have disabilities, if these individuals meet the financial limits.

People who have worked long enough, recently enough, may be able to receive Social Security benefits – such as disability or retirement – as well as SSI.

Social Security Disability Insurance Supplemental Security Income Payments come from the Social Security trust funds and are based on a person’s earnings.

Payments come from the general treasury fund, NOT the Social Security trust funds. SSI payments are not based on a person’s earnings.

An insurance that workers earn by paying Social Security taxes on their wages.

A needs-based public assistance program that does not require a person to have work history.

Pays benefits to disabled individuals who are unable to work, regardless of their income and resources.

Pays disabled individuals who are unable to work AND have limited income and resources.

Benefits for workers and for adults disabled since childhood. Must meet insured status requirements.

Benefits for children and adults in financial need. Must have limited income and limited resources.

SSDI vs. SSI

• Provides physicians and other health professionals with an understanding of the disability programs administered by the Social Security Administration

• Explains how each program works, and provides

information to help health professionals make sound and prompt determinations and decisions on disability claims

Disability Evaluation Under Social Security

socialsecurity.gov/disability/professionals/bluebook

socialsecurity.gov/compassionateallowances

Compassionate Allowances (CAL)

• A way of quickly identifying diseases and other medical conditions that invariably qualify under the Listing of Impairments based on minimal objective medical information

• Allows Social Security to target the most obviously disabled

individuals for allowances based on objective medical information that we can obtain quickly

• Is not a separate program from the Social Security Disability Insurance or Supplemental Security Income programs

socialsecurity.gov/veterans

Wounded warriors and veterans with 100% Permanent & Total disability ratings from the VA may be able to get expedited medical decisions on SSDI and SSI applications.

Wounded Warriors & Veterans

If you recently applied for Social Security or Supplemental Security Income disability benefits and were denied for medical reasons, you can file an appeal online and check the status with your personal my Social Security account.

Disagree With The Medical Decision?

Explains our work incentives, which are employment-support provisions intended to assist you in your efforts to become self-sufficient through work Employment supports can help you find a job or start a business, protect your cash and medical benefits while you work, or help you save money to go to school.

Work Incentive Programs

socialsecurity.gov/redbook

• The Substantial Gainful Activity (SGA) amount for individuals with disabilities, other than blindness, increased from $1,130 to $1,170.

• The SGA amount for individuals who are blind increased from $1,820 to

$1,950 for 2017.

• The monthly earnings amount that we use to determine if a month counts for the Trial Work Period month is $840 per month in 2017.

• The Supplemental Security Income (SSI) Federal Benefit Rate (FBR) is $735 per month for an eligible individual and $1,103 per month for an eligible couple.

What’s New in 2017?

• The amount of earnings that will have no effect on eligibility or benefits for SSI beneficiaries who are students is $7,200 a year. The amount of earnings that we can exclude each month, until we have excluded the maximum for the year, is $1,790 a month.

• The monthly Medicare Part A Hospital Insurance base premium is $413, and the 45 percent reduced premium is $227.

• The Part B Supplemental Medical Insurance monthly base premium is $134.00 (or higher depending on your income). However, most people who get Social Security benefits will pay less than this amount.

• Increased the Medicaid While Working State Threshold Amounts for

persons with disabilities.

What’s New in 2017?

Q&A session

DIFFERENCE BETWEEN MEDICAID THROUGH HHSC and SSA

MEDICAID IS NOTHING BUT A TYPE OF INSURANCE FOR LOW INCOME PEOPLE

TWO POTS OF MONIES, ONE FROM THE STATE OF TEXAS(HHSC) AND THE OTHER

FROM THE FEDERAL GOVERNMENT(SSA)

Medicaid through HHSC (Health and Human services Commission)

• APPLY AT THE LOCAL HHSC OFFICE • MEDICAID IS FUNDED FROM STATE FUNDS • BASED ON INCOME AND RESOURCES • NO SSI CHECK-ONLY MEDICAID AS INSURANCE • EASY TO GET CHILDREN APPROVED, BASED

ONLY ON INCOME • ELIGIBILITY FOR ADULTS IS MORE DIFFICULT

Medicaid through HHSC (Health and Human services Commission)con’t

• OFFERS SEVERAL DIFFERENT TYPES OF MEDICAID. i.e. BREAST/CERVICAL CANCER, TEXAS WOMEN’S HEALTH PROGRAM, PREGNANT, TANF

• RECEIVE AN APPROVAL OR DENIAL WITHIN 30-45 DAYS(A letter of denial is necessary to apply for PAP,

some times can get this denial letter immediately) • VERIFY APPROVAL THROUGH CARE OR TMHP

WEBSITES • HTTPS://yourtexasbenefits.hhsc.texas.gov/programs/health

Medicaid through SSA • APPLY AT LOCAL SSA OFFICE or THROUGH THE

C. BENEFITS STAFF • MEDICAID IS FUNDED WITH FEDERAL FUNDS • RECEIVE A SSI CHECK OF $1.00 UP TO

$750/MONTH WILL QUALIFY FOR MEDICAID IN THE STATE OF TEXAS

• BASED ON INCOME, RESOURCES AND DISABILITY

• MUST PROVE A DISABILITY ACCORDING TO SSA DEFINITION

Medicaid through SSA CON’T

• CAN TAKE MUCH LONGER FOR APPROVAL THAN THROUGH HHSC

• VERIFY THROUGH CARE OR TMHP WEBSITES • TO HELP WITH CONFUSION, MAY WANT TO

FIGURE OUT A WAY TO DETERMINE WHICH A PERSON IS RECEIVING

• WWW.SSA.GOV

IMPAIRMENT CODES 13 Body Systems

12.00 Mental Disorders – Adult

The below list covers only 12.04 and 12.04

What is the A criteria?

1. This information is what the dr. writes, outlining the diagnosis, symptoms and side effects.

What are the paragraph B criteria? Person’s ability to Function.

1. Understand, remember, or apply information This area of mental functioning refers to the abilities to learn, recall, and use information to perform work activities. Examples include: understanding and learning terms, instructions, procedures; following one- or two-step oral instructions to carry out a task; describing work activity to someone else; asking and answering questions and providing explanations; recognizing a mistake and correcting it; identifying and solving problems; sequencing multi-step activities; and using reason and judgment to make work-related decisions. These examples illustrate the nature of this area of mental functioning. We do not require documentation of all of the examples.

2. Interact with others . This area of mental functioning refers to the abilities to relate to and work with supervisors, co-workers, and the public. Examples include: cooperating with others; asking for help when needed; handling conflicts with others; stating own point of view; initiating or sustaining conversation; understanding and responding to social cues (physical, verbal, emotional); responding to requests, suggestions, criticism, correction, and challenges; and keeping social interactions free of excessive irritability, sensitivity, argumentativeness, or suspiciousness. These examples illustrate the nature of this area of mental functioning. We do not require documentation of all of the examples.

3. Concentrate, persist, or maintain pace This area of mental functioning refers to the abilities to focus attention on work activities and stay on task at a sustained rate. Examples include: initiating and performing a task that you understand and know how to do; working at an appropriate and consistent pace; completing tasks in a timely manner; ignoring or avoiding distractions while working; changing activities or work settings without being disruptive; working close to or with others without interrupting or distracting them; sustaining an ordinary routine and regular attendance at work; and working a full day without needing more than the allotted number or length of rest periods during the day. These examples illustrate the nature of this area of mental functioning. We do not require documentation of all of the examples.

4. Adapt or manage oneself This area of mental functioning refers to the abilities to regulate emotions, control behavior, and maintain well-being in a work setting. Examples include: responding to demands; adapting to changes; managing your psychologically based symptoms; distinguishing between acceptable and unacceptable work performance; setting realistic goals; making plans for yourself independently of others; maintaining personal hygiene and attire appropriate to a work setting; and being aware of normal hazards and taking appropriate precautions. These examples illustrate the nature of this area of mental functioning. We do not require documentation of all of the examples.

How do we use the paragraph B criteria to evaluate your mental disorder?

1. General. We use the paragraph B criteria, in conjunction with a rating scale (see 12.00F2), to rate the degree of your limitations. We consider only the limitations that result from your mental disorder(s). We will determine whether you are able to use each of the paragraph B areas of mental functioning in a work setting. We will consider, for example, the kind, degree, and frequency of difficulty you would have; whether you could function without extra help, structure, or supervision; and whether you would require special conditions with regard to activities or other people (see 12.00D).

2. The five-point rating scale. We evaluate the effects of your mental disorder on each of the four areas of mental functioning based on a five-point rating scale consisting of none, mild, moderate, marked, and extreme limitation. To satisfy the paragraph B criteria, your mental disorder must result in extreme limitation of one, or marked limitation of two, paragraph B areas of mental functioning. Under these listings, the five rating points are defined as follows:

a. No limitation (or none). You are able to function in this area independently, appropriately, effectively, and on a sustained basis.

b. Mild limitation. Your functioning in this area independently, appropriately, effectively, and on a sustained basis is slightly limited.

c. Moderate limitation. Your functioning in this area independently, appropriately, effectively, and on a sustained basis is fair.

d. Marked limitation. Your functioning in this area independently, appropriately, effectively, and on a sustained basis is seriously limited.

e. Extreme limitation. You are not able to function in this area independently, appropriately, effectively, and on a sustained basis.

3. Rating the limitations of your areas of mental functioning. a. General. We use all of the relevant medical and non-medical evidence in your case record to evaluate

your mental disorder: the symptoms and signs of your disorder, the reported limitations in your activities, and any help and support you receive that is necessary for you to function. The medical evidence may include descriptors regarding the diagnostic stage or level of your disorder, such as “mild” or “moderate.” Clinicians may use these terms to characterize your medical condition. However, these terms will not always be the same as the degree of your limitation in a paragraph B area of mental functioning.

b. Areas of mental functioning in daily activities. You use the same four areas of mental functioning in daily activities at home and in the community that you would use to function at work. With respect to a particular task or activity, you may have trouble using one or more of the areas. For example, you may have difficulty understanding and remembering what to do; or concentrating and staying on task long enough to do it; or engaging in the task or activity with other people; or trying to do the task without becoming frustrated and losing self-control. Information about your daily functioning can help us understand whether your mental disorder limits one or more of these areas; and, if so, whether it also affects your ability to function in a work setting.

c. Areas of mental functioning in work settings. If you have difficulty using an area of mental functioning from day-to-day at home or in your community, you may also have difficulty using that area to function in a work setting. On the other hand, if you are able to use an area of mental functioning at home or in your community, we will not necessarily assume that you would also be able to use that area to function in a work setting where the demands and stressors differ from those at home. We will consider all evidence about your mental disorder and daily functioning before we reach a conclusion about your ability to work.

d. Overall effect of limitations. Limitation of an area of mental functioning reflects the overall degree to which your mental disorder interferes with that area. The degree of limitation is how we document our assessment of your limitation when using the area of mental functioning independently, appropriately, effectively, and on a sustained basis. It does not necessarily reflect a specific type or number of activities, including activities of daily living, that you have difficulty doing. In addition, no single piece of information (including test results) can establish the degree of limitation of an area of mental functioning.

e. Effects of support, supervision, structure on functioning. The degree of limitation of an area of mental functioning also reflects the kind and extent of supports or supervision you receive and the characteristics of any structured setting where you spend your time, which enable you to function. The more extensive the support you need from others or the more structured the setting you need in order to function, the more limited we will find you to be (see 12.00D).

f. Specific instructions for paragraphs B1, B3, and B4. For paragraphs B1, B3, and B4, the greatest degree of limitation of any part of the area of mental functioning directs the rating of limitation of that whole area of mental functioning.

i. To do a work-related task, you must be able to understand and remember and apply information required by the task. Similarly, you must be able to concentrate and persist and maintain pace in order to complete the task, and adapt and manage yourself in the workplace. Limitation in any one of these parts (understand or remember or apply; concentrate or persist or maintain pace; adapt or manage oneself) may prevent you from completing a work-related task.

ii. We will document the rating of limitation of the whole area of mental functioning, not each individual part. We will not add ratings of the parts together. For example, with respect to paragraph B3, if you have marked limitation in maintaining pace, and mild or moderate limitations in concentrating and persisting, we will find that you have marked limitation in the whole paragraph B3 area of mental functioning.

iii. Marked limitation in more than one part of the same paragraph B area of mental functioning does not satisfy the requirement to have marked limitation in two paragraph B areas of mental functioning.

4. How we evaluate mental disorders involving exacerbations and remissions. a. When we evaluate the effects of your mental disorder, we will consider how often you have exacerbations

and remissions, how long they last, what causes your mental disorder to worsen or improve, and any other relevant information. We will assess any limitation of the affected paragraph B area(s) of mental functioning using the rating scale for the paragraph B criteria. We will consider whether you can use the area of mental functioning on a regular and continuing basis (8 hours a day, 5 days a week, or an equivalent work schedule). We will not find that you are able to work solely because you have a period(s) of improvement (remission), or that you are disabled solely because you have a period of worsening (exacerbation), of your mental disorder.

b. If you have a mental disorder involving exacerbations and remissions, you may be able to use the four areas of mental functioning to work for a few weeks or months. Recurrence or worsening of symptoms and signs, however, can interfere enough to render you unable to sustain the work.

12.03 Schizophrenia spectrum and other psychotic disorders (see 12.00B2), satisfied by A and B, or A and C:

A. Medical documentation of one or more of the following: 1. Delusions or hallucinations; 2. Disorganized thinking (speech); or 3. Grossly disorganized behavior or catatonia.

AND

B. Extreme limitation of one, or marked limitation of two, of the following areas of mental functioning (see 12.00F): 1. Understand, remember, or apply information (see 12.00E1). 2. Interact with others (see 12.00E2). 3. Concentrate, persist, or maintain pace (see 12.00E3). 4. Adapt or manage oneself (see 12.00E4).

OR

C. Your mental disorder in this listing category is “serious and persistent;” that is, you have a medically documented history of the existence of the disorder over a period of at least 2 years, and there is evidence of both:

1. Medical treatment, mental health therapy, psychosocial support(s), or a highly structured setting(s) that is ongoing and that diminishes the symptoms and signs of your mental disorder (see 12.00G2b); and

2. Marginal adjustment, that is, you have minimal capacity to adapt to changes in your environment or to demands that are not already part of your daily life (see 12.00G2c).

12.04 Depressive, bipolar and related disorders (see 12.00B3), satisfied by A and B, or A and C:

A. Medical documentation of the requirements of paragraph 1 or 2: 1. Depressive disorder, characterized by five or more of the following:

a. Depressed mood; b. Diminished interest in almost all activities; c. Appetite disturbance with change in weight; d. Sleep disturbance; e. Observable psychomotor agitation or retardation; f. Decreased energy; g. Feelings of guilt or worthlessness; h. Difficulty concentrating or thinking; or i. Thoughts of death or suicide.

2. Bipolar disorder, characterized by three or more of the following: a. Pressured speech; b. Flight of ideas;

c. Inflated self-esteem; d. Decreased need for sleep; e. Distractibility; f. Involvement in activities that have a high probability of painful consequences that are not

recognized; or g. Increase in goal-directed activity or psychomotor agitation.

AND

B. Extreme limitation of one, or marked limitation of two, of the following areas of mental functioning (see 12.00F): 1. Understand, remember, or apply information (see 12.00E1). 2. Interact with others (see 12.00E2). 3. Concentrate, persist, or maintain pace (see 12.00E3). 4. Adapt or manage oneself (see 12.00E4).

OR

C. Your mental disorder in this listing category is “serious and persistent;” that is, you have a medically documented history of the existence of the disorder over a period of at least 2 years, and there is evidence of both:

1. Medical treatment, mental health therapy, psychosocial support(s), or a highly structured setting(s) that is ongoing and that diminishes the symptoms and signs of your mental disorder (see 12.00G2b); and

2. Marginal adjustment, that is, you have minimal capacity to adapt to changes in your environment or to demands that are not already part of your daily life (see 12.00G2c).

www.ssa.gov

www.ssa.gov/disability/professionals/bluebook/12.00-MentalDisorders-Adult.htm

CONSUMER BENEFITS NEW STAFF TRAINING

DISABILITY DETERMINATION

SERVICES (DDS) FOR SOCIAL SECURITY ADMINSTRATION

(SSA) PROCESS

Disability Determination Services (Adult)

Mission Statement for DDS The mission of DDS is to improve the quality

of life for Texans with disabilities who apply for or receive SSA disability benefits, by making timely and accurate disability determinations.

Legal Basis for the Social Security Disability Program

• The Social Security Act, as amended, Title II

and Title XVI • Code of Federal Regulations, Title 20, Parts

404 and 416

What DDS does

• Gather SSA claimant evidence (medical records & vocational history)

• Make a medical determination on claims received from the SSA Field Office’s, involving the Social Security Disability Insurance (SSDI) and the Supplemental Security Income (SSI) programs in accordance with federal law and regulations.

SSA’s Definition of Disability

• Inability to Engage in any Substantial Gainful Activity * by Reason of:

• Any Medically Determinable Physical or Mental Impairment

• which can be Expected to Result in Death or which has Lasted or can be Expected to Last for a Continuous Period of Not Less than 12 months

• * SGA = $1180/mo. non-blind; $1970/mo. blind

Types of Disability Claims under SSA

• Title II (SSDI - Social Security Disability Insurance) • DIB (Disability Insurance Benefits Claim) • DWB (Disabled Widow/Widower Benefit Claim) • CDB (Childhood Disability Benefit Claim) • Title XVI (SSI - Supplemental Security Income)

DI/BI (Disabled Individual/Blind Individual Claim) DS/BS (Disabled Spouse/Blind Spouse Claim) DC/BC (Disabled Child/Blind Child Claim)

Types of Determination by DDS

• Initial • Reconsideration • Continuing Disability Review • Disability Hearing (CDR Recon)

ADL’s • Physical • Mental

DDS uses the Impairment codes Checking criteria A,B and C

Basic Work Related Activities Mental

• Understanding, carrying out & remembering

simple instructions • Using judgment • Responding appropriately to supervisors, co-

workers and usual work situations • Dealing with changes in a routine work

setting

Disability Claims Process

• Applicant contacts SSA Field office (FO) • Application is completed (by rep., phone, mail) • Application downloaded to DDS in Austin • Assigned to an examiner • Processes application by checking Medical

Records, employment records, etc. • Determines if applicant meets impairment codes • If does not meet, application sent back to SSA FO

Disability Claims Process cont

• If approved by examiner, application is sent on to appropriate Dr., i.e. psychiatrist, oncologist, etc. for final approval

• If Dr. approves must be signed by Dr. • Application is then downloaded from DDS

back to the SSA Field Office • Local SSA Field Office contacts applicant to

complete PERC and applicant is then put into pay

WHAT DOES DDS LOOKS FOR?

Two types of findings

1. Observable signs (i.e. Objective evidence); (yawning if sleepy)

vs.

2. Symptom reports: “I’m sleepy” (i.e. Subjective report)

Signs/Symptoms:

• Signs-depressed facial expression, sad voice, tearful,

• Symptom: “I’m depressed.”

The Core Questions in the Program

1. Does the claimant actually have a medically determinable mental impairment (MDI)?

2. Given consistent objective findings to establish condition, what specific functions are limited and to what degree?

How is a MDI established? • By a description of the following:

• Signs-Medically observable abnormalities plus

• Symptoms-Claimant’s subjective report of problems plus

• Laboratory findings, where applicable

Signs are a required element

• SSA requires signs to establish MDI

• MDI cannot be established based on patients report of symptoms alone.

MDI versus Diagnosis

• Often MDI will take form of an actual psychiatric diagnosis

–in which frank psychiatric signs are described

Functional Limitations

• How does the MDI affect day-to-day functioning

–Intra-personally

–Interpersonally

–Life management

–Stress tolerance

SSA’s Listings of Impairments

• SSA divides the body into 13 “Body Systems”

• Mental is Body system 12

Meeting a Listing

• The first consideration in disability evaluation

• Requires “A” criteria (a MDI) and

“B” criteria (Functional Limitations)

“A” Criteria of the Listings

• We will first talk about the “A” criteria

• establishing that a condition exists

• i.e. the major psychiatric conditions

• 12.02 Organic Mental Disorders

–Something has happened to the integrity of the patient’s brain

–AND the organic damage has resulted in a change in cognitive, emotional, or behavioral functioning.

Causes of Organic Mental Disorders

• Major Neurocognitive Disorder

• Traumatic Brain Injuries

• Diseases-eg. Alzheimer’s

• Related to chronic drug use

Major Neurocognitive Disorder • Decline in at least one area:

– Attention

– Executive Functioning

– Learning/Memory

– Language Use

– Perceptual/Motor

– Social Cognition

• Interferes with independent functioning

• 12.03 Schizophrenia, Paranoid & Other Psychotic Disorders

• What is Schizophrenia?

• Onset usually in early adult years

• Life-long condition

• Characterized by…

Positive Symptoms A-Criteria-Dr. Info

• Things that are there that should not be

– Delusions

– Hallucinations-almost always Auditory

– Disorganized Speech/Behavior

• Loose associations

• Agitation, pacing, aggression, hostility, suspiciousness

Negative Symptoms B-Criteria-Functional/Behaviors • Things that should be there, but are not

– Adequate energy

– Adequate interests

– Motivation

– Range of affect (versus flat or blunted affect)

– Reduced stress tolerance

– Social Withdrawal/Isolation

– Related to frontal lobe dysfunction

Further information on Positive and Negative Symptoms

Positive symptoms: when florid, are extremely disabling, but not so when in

remission. Negative Symptoms:

Ultimately the more disabling factors are lack of motivation and goal directedness as well as difficulty establishing and maintaining social relationships

McGurrin [1994]

12.03 Schizophrenia

• Interpersonal presentation

• Medication side effects

• Work ability and Negative Symptoms

• Chronicity

12.03 Schizoaffective Disorder

• Psychotic symptoms

– Delusions and/or hallucinations and

–Mood symptoms (Depression or Mania)

– Psychotic symptoms are present for 2 weeks or more in the absence of major mood episode at some point in the course of the illness.

12.04 Affective Disorders

– There are 2 types of Affective Disorders:

• Major Depression

• Bipolar

12.04 Major Depression • Depressed Mood • Diminished interest/pleasure in activities • Significant weight loss or changes in appetite • Insomnia or Hypersomnia • Psychomotor retardation or agitation • Fatigue or loss of energy • Feelings of worthlessness or excessive guilt • Impaired concentration

• Recurrent thoughts of death • Suicidal thoughts or attempts

12.04 Bipolar Disorder

• Manic type

– Elevated, expansive, irritable

– Grandiose

– Decreased need for sleep

– Flight of ideas/Racing thoughts

– Distractible

– Psychomotor agitation/excessive activities

– Poor judgment

12.04 Bipolar Disorder • Depressed type

– History of a Manic episode and – Now in a depressed phase and – Looks like Major Depression

• Mixed type – Manic plus – Some features of Major Depression

• “Rapid cycling” subtype – Multiple up/down episodes within a year – Look for severity

Red Flags-In 12.03 and 12.04 Conditions

• Complex med regimes

• Frequent hosp’s

• Use of Clozaril

• ACT Team • Use of injectible

antipsychotic meds

12.05 Mental Retardation ID Sources Related to Establishment of ID If IQ testing not done by Licensed Ph.D. Psychologist,

then…

must have diagnosis of I.D. by Licensed Physician or Ph.D.

Psychologist

• I.D. defined as an I.Q.<75 and

– Now referred to as Intellectual Disability

• Deficits in intellectual functioning such as – Reasoning, problem solving, planning – Abstract thinking, learning

– Which is confirmed by clinical assessment and standardized intellectual testing

• i.e. significant problems navigating way through life due to diminished intellect

I.D., Adaptive Deficits • Deficits in adaptive functioning that

compromise capacity to function independently

– Communication

– Social functioning

– Independent Living

– Across home, school, work & community settings

• 12.06 Anxiety-Related Disorders •Panic Disorder

• Recurrent unexpected panic attacks • Persistent worry about recurrence or significant

avoidance

• Agoraphobia

• Marked fear/anxiety about situations where escape would be difficult or help not available if one panicked.

• “Anxious avoidance”

12.06 Generalized Anxiety Disorder

• Excessive unrealistic worry

• Bodily sensations accompany worry

12.06 Obsessive-Compulsive Disorder • Obsessions-intrusive distressing

thoughts, impulses, images

• Compulsions-rituals to reduce anxiety

12.06 Post-traumatic Stress Disorder • Pathway to trauma

Direct Experience Witnessing Learning re. friend/family

Post-traumatic Stress Disorder, symptoms

• Intrusive sxs (NM/FB)

• Avoidance of reminders

• Development of a globally negative world view-world as dangerous

Post-traumatic Stress Disorder, symptoms

• Excessive arousal/reactivity

– Hyper-vigilance

– Hyper-arousal

– Irritability/anger

– Self-destructive behaviors

– Disrupted sleep

– Disrupted concentration

12.08 Personality Disorders • Deviant, persistent ways of being

• Affecting two or more of the following:

–One’s thinking, feeling, impulse control, or interpersonal functioning.

• Personality Disorder causes significant problems for self & others

• These are difficult people to deal with and be around.

12.08 Antisocial Personality Disorder

• Failure to conform to societal norms

• Deceitfulness-lying, conning others for fun or profit

• Aggressive behavior, irritability, frequent fights/assaults

• Reckless disregard for safety of self/others

• Irresponsibility re. work/financial obligations

• Lack of remorse

12.08 Borderline Personality Disorder • Unstable

– Relationships, – Self-image – Emotions – Impulsive behaviors

• Fears of abandonment • Alternating between love/hate • Unstable sense of self • Impulsive behaviors: Sex, substance use, binge eating

Borderline Personality Disorder

• Unstable emotions which change rapidly

• Feelings of emptiness

• Intense inappropriate anger, poorly controlled

12.09 Substance Use Disorders

• Claim can be an allowance if: • Written Proof there has been a

period of abstinence in which patient’s symptoms significantly remained the same or worsen when not using drugs/alcohol.

• Has been a restricted establishment, i.e. jail, or prison

12.10 Autistic Spectrum Disorder

• B” criteria – Stereotypic/repetitive motor movements – Sameness, routines, rituals, – Highly restricted interests – Under or over-responsiveness to

sensory stimuli

• A” criteria – Deficits in Social Communication &

Social Interaction – Deficits in Nonverbal Communicative

Behaviors – Deficits in Relating to Others

We’re through with the “A” criteria!!! The “B” Criteria of the Listings • Functional Limitations • Restrictions of Activities of Daily Living • Difficulties in Maintaining Social

Functioning • Deficiencies of Concentration, Persistence

or Pace • Episodes of Deterioration or

Decompensation

Degree of Limitation

B Criteria is fulfilled when there are

EITHER

Two marked limitations

OR

One extreme limitation

“B” Criteria of the Listings FUNCTIONAL LIMITATIONS

DEGREE OF LIMITATIONS

1. Restriction of Activities of Daily Living

None Mild Moderate Marked* Extreme* Insufficient Evidence

2. Difficulties in maintaining Social Functioning

None Mild Moderate Marked* Extreme* Insufficient Evidence

3. Difficulties in Maintaining Concentration, Persistence,

or Pace

None Mild Moderate Marked* Extreme* Insufficient Evidence

4. Repeated Episodes of Decompensation, Each of

Extended Duration

None One Four* or or

Two Three* More

Insufficient Evidence

“C” Criteria of the Listings

Medically documented history of a chronic organic mental (12.02), schizophrenic, etc. (12.03), or affective (12.04) disorder of at least 2 years duration that has caused more than a minimal limitation of ability to do any basic work activity, with symptoms or signs currently attenuated by medication or psychosocial support, and one of the following.

1. Repeated episodes or decompensation, each of extended duration or;

2. A residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate; or

3. Current history of 1 or more years inability to function outside a highly supportive living arrangement

Mental Residual Functional Capacity Asseassment MRFC “critical Items”

(Many times an Attorney will ask this document

completed by the pt’s. Psychiatrist) • Divided into four broad areas in applicant’s

ability to hold employment –Understanding & Memory –Sustained Concentration & Persistence –Social Interaction –Adaptation

ISSUE: How much do the medically determinable impairments (MDIs) impact the ability to comprehend and recall information needed for vocational tasks?

Most likely limitation to impede vocational function…

• Inability to understand/remember short/simple instructions

UNDERSTANDING AND MEMORY

SUSTAINED CONCENTRATION AND PERSISTENCE

ISSUE: How much do the MDIs impact the ability to EXECUTE vocational tasks effectively?

• Concentration • Task persistence and pace • Task completion • Ability to use sound simple judgment in task completion • Need for support/supervision • Inability to sustain concentration for extended periods of

time

• Inability to sustain in tasks without special supervision

• Inability to complete a workday/workweek without interruption from psychologically based symptoms

SOCIAL INTERACTION

ISSUE: How much do the MDIs impact the ability to interaction with others and appropriately adhere to social norms?

• Inability to accept instruction and criticism from supervisors

• Inability to get along with co-workers without exhibiting behavioral extremes

ADAPTATION

ISSUE: How much do the MDIs impact the ability to adapt to the needs of a vocational setting?

Most likely limitation to impede vocational function…

• Inability to respond appropriately to changes in the work setting

112.03 Childhood Disability (just add #1 in front of impairment codes)

• First question, like for adults:

• Does claim meet a listing?

• Like adult claims, to meet Childhood Listing requires

–“A” criteria or MDI

–“B” criteria or Functional Limitations

Diagnostic Categories of Mental Impairments – The Child Listings

• 112.02 Organic Mental Disorders • 112.03 Schizophrenic, Delusional (Paranoid), Schizoaffective

and Other Psychotic Disorders • 112.04 Mood Disorders • 112.05 Mental Retardation • 112.06 Anxiety Disorders • 112.07 Somatoform, Eating and Tic Disorders • 112.08 Personality Disorders • 112.09 Psychoactive Substance Dependence Disorders • 112.10 Autistic Disorder and Other Pervasive Developmental

Disorders • 112.11 Attention Deficit Hyperactivity Disorder

Child Listings: Broad Areas of Function

• i.e. to “Meet” a Childhood Listing

– Inability to perform at school – Cognitive/Communicative

– Social

– Personal

– Concentration, Persistence or Pace

Childhood Claims-B Criteria Functional Equivalence Domains

• Acquiring and using information

• Attending to and completing tasks

• Interacting with and relating to others

• Moving about and manipulating objects

• Caring for yourself

• Health and well-being

FUNCTIONAL INFORMATION SOURCES MEDICAL RECORDS FROM:

Psychiatrists, other Drs. (PCP) ACT Team Supported Housing Specialist

Supported Employment Specialist Psychosocial Program Specialist

Care Coordinators Family Preservation

Program Nurses Counselors

Sources of Medical Evidence LICENSED:

PHYSICIANS (M.D./D.O.) PH.D. or

PSYCHOLOGIST

Other Medical Records

Include all other treating

sources of which you are aware –

even non-MHMR sources: • PCP Records as physical illnesses can

help make the case of disability in many

cases

CHARTING The more descriptive the better!

Rather than: “Client became upset”

State: “Client tried to grab the paper from my hand, yelled curse words at me, and visibly trembled with anger.”

Rather than: “Client quit her job”

State: “Client reports she became extremely anxious under the job pressure, was crying several times daily and quit her job”

Read your records from an outsiders perspective

MORE DESCRIPTION IS BETTER

THAN LESS-remember that: Familiarity breeds Complacency

And Acceptance of Symptoms

Paint a Picture for DDS Examiner

Overcoming familiarity in these areas

Concentration Memory Social functioning Hygiene Tolerating stress/changes Supervision

Concentration

Easily distracted by… Trouble paying attention Requires repeated instructions Appears internally distracted Can’t keep mind on

conversation Jumps from topic to topic

Memory

Forgets instructions Forgets what we’ve talked about Forgets our appointments Can’t remember med/dosing Requires frequent re-teaching

Social Functioning Labile, irritable, angry, volatile Short-tempered Loud, pressured speech Set off easily Over-reacts to minor issues Touchy if given feedback Circumstantial/tangential

Hygiene Stained or dirty clothing Body odor Matted, oily or dirty hair Dirty living quarters Does not care about appearance Inappropriate attire for season

Tolerating stress/changes

Anxious if routine changes Takes normal events hard Breaks into tears easily Becomes angry quickly Always looks very tense/anxious

Supervision

Requires step-by-step instructions Requires a lot of repetition Problems with med compliance Problems with keeping appointments Requires supported living situation Requires intensive monitoring

DDS-9908

MENTAL STATUS EXAM

Document Cumulative Impression of signs, symptoms and function over the last 12

months

M.D. or Ph.D. signature required (9908 can be completed by Qualified Staff Member)

Name:

SSN:

DE/Unit:

MENTAL STATUS REPORT (Please complete using existing records.)

Please cite relevant positive and negative findings (findings significant by their presence or absence) in support of any conclusions you give.

1.History for mental illness including any pertinent Drug/Alcohol use (specifically address current medications and treatment compliance, length of treatment relationship): 2. General appearance, grooming, motor behavior:

3. Voice and speech:

4. Orientation to time, place and person:

5. Mood and affect:

6. Content of thought:

7. Thought process:

8. Memory: Remote, recent, immediate (4 Presidents, 3 objects recall, digit span recall:

9.Attention and concentration (serial 3’s or 7’s, counting 20-1, spelling ‘WORLD’ backwards, etc):

10.Insight and judgment: ability to abstract. 11. Diagnosis or impression (Please cite pertinent

DSM-IV criteria) Axis I: Axis II:

12.Prognosis with comments:

13.Ability to relate to others and to sustain work:

14.Ability to respond to change/stress in work setting:

15.Date of most recent patient evaluation:

16.In your opinion is the patient able to manage benefit payments in his/her own interest?

YES NO

Date Signature (M.D., D.O., or Ph.D. Psychologist)

Printed Name of M.D., D.O., or Ph.D.

PROBLEM CLAIMS

PENNY SCHUBERT at DDS

1-800-252-7009 EXT 8660

Penny.schubert@ssa.gov

Tips and How to:

•Engage the Applicant

• Write Clinical Summaries

• Complete Mental Status Exams

• Prepare Medical Records for DDS

1

Goal is to portray an individual’s history

Asking the applicant to share very personal information

Sensitivity, compassion, respect, empathy

Use open-ended questions to avoid yes/no answers and to obtain richer responses: ◦ How? What? Why? ◦ What is a good day like? What is a bad day like? ◦ Tell me about… ◦ Describe what happens…paint a picture for examiner

2

Synopsis of the case and why the claimant should be found disabled

Add at the end of the Function Report as a detailed summary of the case or complete a clinical summary. Site Impairment code(s) and describe how the applicant meets the A,B and/or C criteria.

Any comments should be stated in “interviewer’s opinion”, or as stated by applicant, or written in the medical record, per doctor.

Brief , descriptive and concise

3

Describe past work and exertional levels; concentration, pace & persistence

Describe problems at work: why the claimant quit/was

fired; describe if the work was “sheltered” List treatment, episodes of decompensation (related

incarcerations), & medications

Link the symptoms to the functional impairment code(s) Help the DDS examiner “see” the person

4

Medications treat the symptoms of mental health disorders; cannot cure the disorders but they help improve functioning

Medications work differently for different people; some get side effects; some don’t

Factors that affect how medications work: ◦ Age, sex, body size, genetics ◦ Physical illness; other medications ◦ Habits like smoking & drinking; diet ◦ Liver and kidney function ◦ Compliance

5

◦ Rigidity, muscle spasm, tremors ◦ Drowsiness ◦ Dizziness ◦ Blurred vision ◦ Sensitivity to sun; skin rashes ◦ Agitation ◦ Restlessness ◦ Sexual dysfunction

Side effects can contribute non-compliance;

important to document!

6

May be requested by DDS examiner to help decide certain cases or automatically have document completed.

Important in determining decision

Emphasis given to questions regarding ◦ Prognosis ◦ Ability to relate to others & sustain work ◦ Ability to respond to changes/stress in work settings

Can be completed by member of the treatment team

Must be signed by a PhD or MD

7

Electronic Records Express: Contact DDS at 800-252-9627 to set up system; send electronic records or scanned records to the DDS examiner

Bar code identifies each individual’s record

Include the following: ◦ Diagnosis ◦ Medical history ◦ Clinical findings (physical or mental tests) ◦ Lab findings (kidney function, x-rays, etc) ◦ Treatment prescribed with response & prognosis ◦ Clinical summary prepared by CBO staff ◦ Current Mental Status

8

MBI-Medicaid Buy-In

Low-cost health care for people with disabilities who work

Medicaid becomes the person’s insurance company

What is the Medicaid Buy-In (MBI) program?

• The program offers low-cost Medicaid health care services — including community-based services and supports - to individuals with disabilities who work. Some people in the program might have to pay a monthly fee.

Who can be in the Medicaid Buy-In program?

• A person who: • Has a disability; • Is working; • Lives in Texas; and • Does not live in a state institution or nursing home all

the time. • Note: If you get home and community-based services

through a Medicaid waiver program, you also might be able to be in the Medicaid Buy-In program. Some examples of Medicaid waiver programs are Community Based Alternatives (CBA), Community Living and Support Services (CLASS), and Home and Community-based Services (HCS).

What health care benefits can I get? • Medicaid Buy-In benefits are the same as regular Traditional Medicaid

benefits. Some examples of benefits are: • Doctor / clinic visits • Mental health care • Hospital stays • Vision care • Emergency care • Hearing care • Medicine • Speech therapy (help learning to speak better) • Glasses • Occupational therapy (help learning how to do everyday tasks) • X-rays • Physical therapy (help learning how to move around better or become

stronger) • You also might be able to get help in your home or at another place during

the day. These services also are known as Day Activity and Health Services (DAHS) or Primary Home Care (PHC).

How do I know if my disability meets the Medicaid Buy-In rules?

• If you already get Social Security disability benefits, you meet the disability rules for the program.

• If you don’t get Social Security disability benefits, HHSC will review your case to decide if your disability meets the rules.

• HHSC uses the Social Security disability guidelines to determine if you have a disability. HHSC does not look at the Social Security disability guidelines about limits on working or the amount of money you get from a job. ***(If a person has been denied disability through SSA, in the past, the person does not meet eligibility rules.)

What are the rules for the amount of money I (the applicant) can get and

still be in this program? • The amount of money you earn each month must be

less than $2,513 gross. • The amount of money you have such as cash, banks,

and retirement accounts (countable assets) must be no more than $2,000. Only the money you get counts. Money other family members get isn't counted.

• Money that doesn’t count includes: Plan to Achieve Self-Support (PASS) funds and independence accounts. Earned income tax credit and child tax credit payments. Work expenses due to a disability.

How much do I have to pay? • Your cost is based on: • The money you earn from work. We will take

out amounts we don’t have to count. • Any other unearned money you get above

$750. Examples of other money are Social Security benefits (SSI), retirement checks, and money from rental property, etc.

• Earned income and unearned income=Total Premium. (Premium capped at $500.00)

PAYMENT STRUCTURE Earned Income (working)

• 2017 FPIL Ranges Earned Income Premium Amounts(Example Purposes Only)

• Earnings at or below 150% FPIL(less than or equal to 1,508 gross)Premium: $0

• Earnings above 150% FPIL up to and including 185% FPIL (Between $1,508 and $1,860 gross) Premium: $20

• Earnings above 185% FPIL up to and including 200% FPIL (between$1,860 and $2,010 gross) Premium: $25

• Earnings above 200% FPIL up to and including 250% FPIL (Between $2,010 and $2,513 gross) Premium: $30

• Earnings above 250% FPIL(greater than $2,513 gross) Premium: $40

PAYMENT STRUCTURE con’t Unearned Income

• The Unearned Income Premium Amount is

calculated by taking the person’s gross SSDI amount (before part B premium is taken out)and any other unearned income and completing the following calculation:

Example: Premium Calculation

• Example: • $860(amt.of SSDI check+other unearned income) • -$750 (maximum SSI benefit) • $110 (unearned income) • +$ 20 (earned income, wages of $1600/month)

• $130 (Total MBI premium/month) • This premium must be paid before MBI starts.

How do I apply for the Medicaid Buy-In program?

• Fill out an application form. You can get it one of three ways:

• Download the form: [English] [Spanish] • Call 2-1-1 and ask to have an H1200 form

mailed to you. • Pick up a form at an HHSC benefits office. Call

2-1-1 or 1-877-541-7905 (toll-free) to find one near you.

Where do I turn in my application form?

• You can turn in your form one of these ways: • Take it to an HHSC benefits office. Call 2-1-1 to

find an office near you. • Fax it to 1-877-447-2839 (toll-free). If your form is

2-sided, fax both sides. • Mail it to:

Health and Human Services Commission P.O. Box 14600 Midland, TX 79711-4600.

• Before you send your form to apply, be sure to: • Send copies of the items we ask for (pay stubs,

etc.).

How long will it take to find out if I can be in this program?

• We will try to let you know within 45 days, but it might take up to 90 days if HHSC needs to find out more about your disability. In either case, we will send a letter to tell you if you can be in the Medicaid Buy-In program. If you can be in the program, the letter will tell you:

• How much your cost will be (your premium). • When your payment is due (usually the end of

the month). • When your Medicaid benefits will begin.

Questions?

• Call 2-1-1. Pick a language and then press 2. • Call or visit an HHSC benefits office. To find an

office near you, call 2-1-1 (toll-free). • • https://hhs.texas.gov/services/health/medicaid-chip/programs/medicaid-buy-adults