Transcript Slide 1

Understanding SSA’s Policy
on Drug Addiction and
Alcoholism
The webinar will begin shortly.
Audio: 1-888-323-4910
Passcode: 3741743
PIN: This was provided in your
registration confirmation e-mail. If you experience
difficulties, please stay on the line for an operator.
Understanding SSA’s Policy on
Drug Addiction and Alcoholism
and its Impact on Disability
Determinations
Presented by:
SAMHSA SOAR Technical Assistance Center
Policy Research Associates, Inc.
AND
National Health Care for the Homeless Council
This webinar is in part supported by Cooperative Agreement Number U30CS09746-04-00 from the Health Resources and
Services Administration, Bureau of Primary Health Care (HRSA/BPHC). Its contents are solely the responsibility of the
authors and do not necessarily represent the official views of HRSA/BPHC.
Welcome and Opening Remarks
Sabrina Edgington
Kristin Lupfer
National Health Care for the
Homeless Council
SAMHSA SOAR TA Center
Policy Research Associates, Inc.
Webinar Instructions

Question instructions

Muting

Recording availability

Downloading documents

Evaluation
Agenda
Welcome and Introductions

Sabrina Edgington, MSSW, Program and Policy Specialist, National Health
Care for the Homeless Council

Kristin Lupfer, LMSW, Associate Director, SAMHSA SOAR Technical
Assistance Center, Policy Research Associates, Inc.
Overview of DAA Ruling

Michele Schaefer, Supervisory Team Leader, Office of Medical Listings
Improvement, Office of Disability Programs, Social Security Administration
Implications for DDS and Recommendations for Providers

Daette Quick, Certified Public Manager, Iowa Disability Determination Services
Documenting Disability for Individuals who have a Substance Use Disorder

Dr. Barry Zevin, MD, Tom Waddell Health Center, San Francisco Department of
Public Health
Submitting Applications for Individuals who have a Substance Use Disorder

Pam Heine, MSW, LSW, Senior Project Associate, SAMHSA SOAR Technical
Assistance Center, Policy Research Associates, Inc.
13-2p:
Evaluating
Cases Involving
Drug Addiction
and Alcoholism
(DAA)
Presenter:
Michele Schaefer
1996 Legislative Change
Public Law 104-121
A claimant shall not be considered
disabled if drug addiction or
alcoholism is a contributing factor
material to the determination that
the individual is disabled.
DAA Social Security
Ruling 13-2p
 SSR 13-2p; Titles II and XVI:
Evaluating Cases Involving Drug
Addiction and Alcoholism (DAA)
 Published on February 20, 2013
 Effective March 22, 2013
DAA Social Security
Ruling 13-2p, Cont.
 DAA SSR explains how we consider
whether DAA is material
 15 Questions in the SSR
 6-Step DAA Evaluation Process
DAA Definition
We define DAA as
“Substance Use Disorders”
DAA Does Not Include:
 Caffeine and nicotine disorders
 Use of prescription medications taken as
prescribed
 Children who have medical conditions
resulting from their mothers’ use of drugs
or alcohol during pregnancy
 Occasional misuse of drugs
or alcohol
Substance-induced
disorders are not included in
our definition of DAA.
 Exceptions:
– Substance-Induced Persisting Dementia
– Substance-Induced Persisting Amnestic
Disorder
DAA and Sequential
Evaluation
Adjudicators apply the sequential
evaluation twice:
– Once to determine that the claimant is
disabled considering all impairments
– Second evaluation to determine whether
the claimant would still be disabled if he
or she were not using drugs or alcohol
Burden of proof
The burden of proving disability
throughout the sequential evaluation
process rests with the claimant.
If DAA IS Material, then the
Claimant IS NOT Disabled
DAA is Material When:
 The claimant’s only impairment is
substance abuse or dependence; or
 The claimant’s other physical or mental
impairment is, by itself, not disabling.
For example, the claimant has a hearing
impairment that’s not severe.
If DAA is NOT Material, then
the Claimant IS Disabled
DAA is NOT Material
When:
 Claimant has impairment(s) that is NOT
affected by the DAA and is disabled; or
 Claimant has physical impairment(s) that is
NOT affected by DAA, AND the vocational
grid rules direct a finding of disabled; or
 Claimant has a permanent condition that
resulted from drinking or taking drugs and it
is a SEPARATE impairment
DAA Evaluation Process
Step 1
Does the claimant have DAA?
DAA Evaluation Process
Step 2
Is the claimant disabled
considering all impairments,
including DAA?
DAA Evaluation Process
Step 3
 Is DAA the only impairment?
–If DAA is the claimant’s only impairment,
DAA is material and a denial is
appropriate
DAA Evaluation Process
Step 4
 Is the other impairment(s) disabling by
itself while the claimant is dependent
upon or abusing drugs or alcohol?
– If the other impairment(s) is NOT
disabling by itself, DAA is material and
a denial is appropriate
– If the other impairment(s) IS disabling
by itself, go to Step 5
DAA Evaluation Process
Step 5
 Does the DAA cause or affect the
claimant’s medically determinable
impairment(s)?
– If DAA is not causing or does not affect
the other impairment, DAA is NOT
material. An allowance is appropriate.
Step 5 Scenarios for Establishing
that DAA Does NOT Cause or Affect
the Other Impairments:
 Other disabling impairment has no
relationship to the DAA
 Claimant acquired a separate disabling
impairment while using a substance
 DAA medically caused the other disabling
impairment BUT other impairment is
irreversible or could not improve to the
point of nondisability
DAA Evaluation Process
Step 5 Cont’d
 If DAA does not cause or affect other
impairments to be found nondisabling, DAA is NOT material and an
allowance is appropriate
 If DAA causes or affects the claimant’s
other medically determinable
impairment(s), proceed to step 6.
DAA Evaluation Process
Step 6
 Would the other impairment(s)
improve to the point of nondisability
in the absence of DAA?
– Yes, DAA is material and a denial is
appropriate
– No, DAA is not material and a allowance
is appropriate
Question 14 -What explanation does
the determination or decision need
to contain?
 Findings:
1. Claimant has DAA
2. Claimant is disabled considering all
impairments (including DAA)
3. Claimant would or would not be
disabled in the absence of DAA
Implications for DDS and
Recommendations for Providers
Daette Quick
Certified Public Manager, Iowa Disability Determination Services
Supporting the Determination

Adjudicators must provide sufficient information
that supports their determination of materiality of
DAA
– The claimant has DAA and at least one other medically
determinable physical or mental impairment,
– The other impairment(s) could be disabling by itself ,
and
– The other impairment(s) might improve to the point of
non-disability if the claimant were to stop using drugs
or alcohol.
Non-Medical Sources

Many claimants with Substance Use Disorders
receive care from “other” non-medical sources
– Examples are: non-clinical social workers,
caseworkers, voc rehab specialists, family members,
school personnel, clergy, friends, past employers,
licensed chemical dependency practitioners.
– “Other” medical sources include but are not limited
to: nurse practitioners, physician’s assistants and
therapists.
Functioning Over Time

Information from “other” sources can be essential to the
finding of materiality by describing the claimant’s
functioning over time (in times of use and abstinence)
because it supplements the medical evidence of record
– Can describe how the claimant is performing or has performed
activities of daily living
– Can detail claimant’s responses to normal stressors of daily living
– Can provide information about independence of and ability to
sustain work like activities
– Can provide information about ability to accept supervision and
work appropriately with peers
– Can provide accurate description of level of function
Key Information

Per SSR 13-2p “In many cases, evidence from “other”
sources may be the most important information in the
case record for these documentation issues.”

When the information listed above is included in the
Medical Summary Report, it assists with the
determination of DAA materiality with information
crucial to the determination of level of function when the
claimant is and is not using drugs or alcohol.
Documenting Disability for
Individuals who have a
Substance Use Disorder
Dr. Barry Zevin, MD
Tom Waddell Health Center, San Francisco Department of
Public Health
Thinking About Disability in
Homeless People


Goals and approach to clinical care may be quite
different than disability determination process
Clinical process does have some similarity to
disability determination process
–
–
–
–

Think holistically about patient’s functioning
Explore why patient is homeless
Explore underlying problems
Explore consequences of homelessness
Many patients show tremendous resilience but are
unable to sustain functioning needed to work
Role of Clinicians

Primary care providers and other continuity providers have
advantage of observing patients over time
– As in other clinical tasks gathering and synthesizing information
from other health care providers and collateral informants is
essential

Documentation in clinical setting has many purposes
– Electronic health records create opportunities and challenges
• Help establish scope and consistency of problems
• may make creating a coherent narrative more difficult
– Documenting disability by assessing and recording patient
functioning has many potential benefits to patients overall care
Disability Due to Substance Abuse

There is no doubt that substance use disorders of a high
severity can cause severe functional disability

Policy that these disabilities do not qualify for benefits
creates challenge for clinicians

Knowledge of manifestations and natural history of
substance use disorders is important in evaluating these
patients
– It is not unusual for patients and clinicians less familiar with
substance use disorders to attribute symptoms and functional
limitations to “addiction” that are in fact caused by co-occurring
conditions
Impairments Related to Substance
Use
 Substance use disorders excluded by law as a basis
for disability under SSI/SSDI.
 Comment whether patient would still be disabled
even if substance use were to cease.
 Encourage treatment.
 Permanent or long-term sequelae of substance
abuse are considered in the system area in which
they occur (e.g. Chronic liver disease in Digestive
System section).
Co-Occurring Disorders

Personality disorders very frequent in substance abusers
–
–
Very treatment resistant
Degree of impairment underestimated by patients and providers
•
•




Ask about conflicts, consider patient’s style in the office – conflicts with
front office staff, other providers, family members, etc.
Explicitly point out violence history in anti-social PD patients and others
PTSD, anxiety disorders, depression, ADHD, psychotic
disorders
Cognitive disorders due to developmental disabilities,
traumatic brain injury, hypoxic episodes in OD, alcohol
dementia
Liver disease, heart disease, lung disease, chronic
infectious disease, musculoskeletal disorders
Chronic pain
Strategies to Help Determine Lack
of Materiality




Impairment preceded initiation of addiction
Existence of permanent sequelae of alcohol or drug use
Point out drug use as attempted self treatment of severe
underlying problems
Observation or review of reports of patient during periods
of abstinence
– In program, In jail, etc.
– Evidence supports rapid response of substance induced mental
health disorders after abstinence - document this as factual
– Methadone or buprenorphine maintenance are not considered
drugs of abuse and impairments that persist when patient is under
treatment should qualify
• State explicitly as disability determination specialists may be unfamiliar
Submitting Applications for
Individuals who have a
Substance Use Disorder
Pam Heine, MSW, LSW
SAMHSA SOAR Technical Assistance Center
Policy Research Associates, Inc.
SOAR: An Active Role
SOAR practitioners take an active role developing quality
disability applications by:
 Becoming applicant's authorized representative (SSA 1696)
 Gathering and organizing required evidence received from
applicant, medical providers (past and present), and other
sources
 Submitting completed application which includes medical
records and the SOAR Medical Summary Report (MSR)– Describes severity of functioning over time
– Elevated to medical evidence when signed by an acceptable
medical source, (i.e. MD, DO or PhD)
– Effective means to show applicant’s mental impairments pre-date
or underly the substance abuse
Important Things to Know and
Understand





Read SSR 13-2p
Definition of Alcoholism, Substance Dependence,
and Substance Abuse
Co-occurring Mental Illness and Substance Abuse
Understanding the Evidence - learn the details
Stepping Stones to Recovery Training
– Good time to dust off that binder!

Sample Descriptions
Three Strategies After SSR 13-2p
#1 Materiality

Medical provider documents that DAA is not material
#2 Sobriety





Take advantage of periods when the applicant has not been using
drugs or alcohol
Make a timeline
Careful review of record for doctor’s findings regarding the
applicant’s limitations
If possible, talk to applicant about drug or alcohol rehabilitation
program
After sober for one month, obtain statement from doctor regarding
ability to work based on remaining health problems
Three Strategies After SSR 13-2p
#3 Medical Documentation and Other Evidence

Educate treating sources about SSA’s DA&A policy

Obtain opinion evidence from acceptable medical sources,
and from sources who are not considered “acceptable
medical sources” (see SSR 06-03)

Emphasize the physical and other mental health impairments,
including pain allegation (see SSR 83-14, SSR 85-15 and
SSR 96-7p)

Finally, always submit the SOAR Medical Summary Report
(MSR) where there is evidence of DA&A!
Questions and Answers
Facilitators:
SAMHSA SOAR Technical Assistance Center
Policy Research Associates, Inc.
For More Information
SAMHSA SOAR TA Center
www.prainc.com/soar
National Health Care for the Homeless Council
www.nhchc.org