Spring 1999 ~ Newsletter
Insurance Issues and Cystic Fibrosis
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Disability, SSI, and CF -- A Primer On The Basics
by Jim Methvin, Medical Services Coordinator, Disability Determination Service
Social Security oversees two disability programs in the United States. One major disability program is the Social Security Disability Insurance program. To receive Social Security Disability, one must qualify by meeting the definition of disability as well as certain eligibility requirements. These eligibility requirements state that an individual must have worked and contributed to Social Security long enough and recently enough to be insured for benefits.A second federal program is the Supplemental Security Income (SSI) program. SSI payments are made monthly to people who are aged, blind or disabled, and who have very limited income and resources. The funding for SSI comes from federal income taxes rather than Social Security contributions.An individual can receive SSI if he or she has certain limited income and resources and is age 65 or older, or is blind; or has a mental or physical disability.Definitions of Disability
Under the Social Security and SSI programs, the law defines disability for adults as "the inability to do 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."Under the SSI program, the law defines disability for children as "an individual under the age of 18 shall be considered to be disabled under SSI if that individual has a medically determinable physical or mental impairment, which results in marked and severe functional limitations, and 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."Can someone work and still receive disability benefits?Social Security rules make it possible for people to test their ability to work without losing their rights to cash benefits and Medicare or Medicaid. These rules are called "work incentives." The rules are different for Social Security Disability and SSI but under both programs they may provide:* continued cash benefits* continued help with medical bills;* help with work expenses; or* vocational training.For more information about work incentives, contact your nearest Social Security Office.
Documentation of Cystic Fibrosis for Social Security or SSI
Federal Regulations 20CFR 404.1525, Appendix 1 to Subpart P - Listing of Impairments specifies the documentation criteria needed to evaluate cystic fibrosis for adults and children.
For adults and children (under age 18) - Confirmation of the diagnosis is based upon CF gene mutation analysis or an elevated sweat sodium concentration or chloride concentration accompanied by one or more of the following: the presence of chronic obstructive pulmonary disease, insufficiency of exocrine pancreatic function, meconium ileus or a positive family history of CF.
The pulmonary manifestations should be documented by pulmonary function testing; or detailed physical findings such as evidence of episodes of bronchitis or pneumonia or hemoptysis or respiratory failure; or medical evidence of persistent pulmonary bacterial infection. For children in whom pulmonary function testing cannot be performed, the medical documentation should include detailed physical findings such as evidence of dyspnea on exertion, or accumulation of secretions as manifested by repetitive coughing or cyanosis, or persistent abnormal breath sounds or X-ray evidence of pulmonary disease.The non-pulmonary aspects of cystic fibrosis should be documented in terms of an interference with nutrition, weight loss, or gastrointestinal complications. Growth impairments related to CF should be documented in terms of a comparison of current height with previously recorded heights.
To determine disability, Social Security will conduct a thorough review of the above-mentioned and other evidence. Other evidence that is important is information about one's functioning. If cystic fibrosis and/or other medical condition (s) results in any restrictions or limitations in functioning, then this also needs to be reported. Please note - because cystic fibrosis may involve the respiratory and digestive body systems, as well as, for children, the impact on a child's growth and development, the combined effects of these body systems must be considered in case adjudication.If you have questions or would like more information, call Jim Methvin at (205) 989-2100.