Findings from a Study of the SSI/SSDI Outreach, Access, and Recovery (SOAR) Initiative. The Policy Context

12/15/2009

SSI/SSDI eligibility is contingent on having a medical condition that meets Social Security's definition of disability. To be eligible for SSI benefits, individuals must pass an income and resource test and be deemed disabled. To be eligible for SSDI, individuals must have worked in jobs covered by Social Security and be deemed disabled. According to the uniform definition of disability applied in all states, individuals are disabled if they have a medically determinable physical or mental impairment that (1) is expected to last at least 12 continuous months or to result in death; (2) prevents them from performing substantial gainful activity (that is, earning about $900 per month); and (3) results in functional impairment in at least two of four areas. Applicants bear responsibility for submitting the information necessary to document their medical conditions, and each state's Disability Determination Service (DDS) decides whether applicants meet the Social Security Administration's (SSA) criteria.

Given that disability determination is based on several factors, applicants often face difficulty compiling needed information or judging whether they meet SSA's eligibility criteria. Providing enough documentation that verifies functional and medical disability requires that contact information for treating providers in the application must be complete, that treating providers must respond to requests for information, and that the information is adequate to permit claims adjudicators to make a medical determination of disability. Some medical providers lack experience with SSA's medical criteria for determining disabilities and therefore sometimes do not provide the information needed for a favorable decision. Medical examiners at DDS do not generally meet with claimants and must instead rely exclusively on written documentation to make their determinations. A lack of medical evidence may require SSA to request the applicant to undergo a consultative examination (CE) with an SSA-contracted medical provider. Satisfaction of such a requirement and the need to provide or remedy other missing or inadequate information in the application can delay the claim adjudication process and/or result in a denial, especially if the applicant neglects to respond to requests for additional information in a timely manner or fails to keep scheduled CE appointments. One study attributed 25 percent of denied claims among individuals who are homeless to failure to complete the CE, which is nearly three times higher than among non-homeless persons (9 percent) (O'Connell et al. 2004).

Aside from the general complexity of the application process, several other barriers can prevent homeless individuals with disabilities from being awarded SSI/SSDI benefits, including poor health status, lack of a stable address, fragile social support networks, and inadequate relationships with health and social service providers. In addition, mental health and substance abuse problems experienced by those in this group compromise their ability to navigate the complex and lengthy SSI/SSDI application process. As many as 77 percent of adults who are homeless report a chronic health condition (O'Toole et al. 2002), 22 percent report a serious and persistent mental illness, and 67 percent report having received a mental health diagnosis during their lifetime (U.S. Conference of Mayors 2004; Goering et al. 2002; North et al. 2004). As many as 68 percent of homeless adults report substance abuse problems, and many have both substance abuse and mental health disorders (Goering et al. 2002). These problems limit physical and cognitive functioning and impair an individual's ability to make decisions and keep appointments (Macnee and Forrest 1997), both of which are necessary to complete the SSI/SSDI application process.

Many adults who are homeless have no usual source of medical care and lack trusting relationships with providers who can document their disability for the application (O'Toole et al. 2002). In particular, few of these individuals have a relationship with a provider (Zima et al. 1996; Bird et al. 2002), often reflecting the homeless community's distrust of health and social service professionals (Bhui et al. 2006). In addition, women who are homeless report relatively less support from social service agencies (Stovall and Flaherty 1994). At the same time, the stigma associated with homelessness and mental health problems may prevent these individuals from seeking professional help (Bird et al. 2002). In addition, as many as 23 percent of individuals who are homeless have been incarcerated, and 34 percent report legal troubles while homeless. These individuals may be particularly reluctant to sustain relationships with social service agencies during the SSI/SSDI application process (Kushel et al. 2005; Goering et al. 2002).

Finally, even when these individuals do receive medical care, their providers and family members may not be familiar with the disability determination process and the criteria used to determine disability. Indeed, a professional and social support network versed in the application process is essential for managing it. In practice, it is often family members and friends who provide nonmedical information for the application, yet individuals who are homeless frequently function within strained social networks (Meadows-Oliver 2005) and lack family supports. Individuals who are homeless with the least family support remain homeless longer (Caton et al. 2005) while those who receive SSI/SSDI tend to have larger social networks (Segal et al. 1997), perhaps suggesting that friends and family members offered much-needed support during the application process.

For all of these reasons, the approval rate among individuals who are homeless is much lower than among the broader population. In 2004, 28.9 percent of SSI claims submitted by persons over age 18 were approved following the initial application, with 26.2 percent of denials related to problems with the application process (Social Security Advisory Board 2006). The approval rate for those who are homeless, however, is only 10 to 15 percent (Rosen et. al. 2001). Even among those approved, the processing time can take several months or longer. The average processing time for an initial claim is about 120 days. For claims that are denied and appealed, processing time exceeds 400 days on average (Social Security Advisory Board 2006). Given the typically long wait for a hearing before an adjudicative law judge at appeal, it is extremely important to ensure that information is as complete and relevant as possible in the initial disability application.

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