GAO-15-404SP: Income security: 21. Children's Disability Reviews

Income security > 21. Children's Disability Reviews

To prevent an estimated $3.1 billion dollars in potential overpayments over 5 years, the Social Security Administration needs to conduct timely disability reviews to better ensure that only eligible children receive cash benefits from the Supplemental Security Income program.

Why This Area Is Important

The Social Security Administration (SSA) administers Supplemental Security Income (SSI), a nationwide federal assistance program that provides cash benefits to eligible low-income individuals with disabilities, including children, as well as certain individuals who are aged or blind. In 2013, SSA paid almost $53 billion in SSI benefits to about 8 million recipients, of which about $10.3 billion was paid to about 1.3 million children. During the early and mid-1990s, the SSI program grew at an unprecedented rate for children due, in part, to legal developments that expanded program eligibility for children with mental impairments.

To ensure that only recipients who remain disabled continue to receive benefits, SSA is required to conduct periodic continuing disability reviews (CDR).[1] These reviews assess whether recipients are still eligible for benefits based on several criteria, including their current medical condition.When reviews are not conducted as scheduled, some recipients, including children, may receive benefits for which they are no longer eligible, potentially costing taxpayers billions of dollars in overpayments.



[1] SSA’s regulations pertaining to CDRs for SSI can be found at 20 C.F.R. § 416.989 et seq. For individuals under age 18, a disability is a medically determinable physical or mental impairment that results in marked and severe functional limitations, and is expected to result in death or which has lasted or can be expected to last for a continuous period of at least 12 months. 42 U.S.C. § 1382c(a)(3)(C)(i) and 20 C.F.R. § 416.906.

What GAO Found

From fiscal years 2000 to 2011, the number of childhood CDRs fell from more than 150,000 to about 45,000 (70 percent), according to GAO’s June 2012 analysis of SSA data.[1] More specifically, CDRs for children under age 18 with mental impairments—a group that comprises a growing majority of all child SSI recipients—declined from more than 84,000 to about 16,000 (an 80 percent decrease). In recent years, SSA has cited resource limitations and a greater emphasis on processing initial claims and requests for hearings appeals as reasons for the decrease in the number of CDRs conducted.[2]

GAO reported in June 2012 that a large proportion of childhood CDRs were overdue.[3] For example, CDRs for about one-half of all child recipients with mental impairments (435,000) were overdue, according to GAO’s analysis of SSA data.[4] Of these, about 344,000 (79 percent) had exceeded the scheduled date by at least a year; about 205,000 (47 percent) exceeded their date by 3 years; and about 24,000 (6 percent) exceeded the scheduled date by 6 years. GAO also identified several cases that exceeded their scheduled date by 13 years or more. Of the 24,000 childhood CDRs pending 6 years or more, GAO found that about 70 percent (over 17,000) were for children who, at initial determination, SSA classified as “medical improvement possible,” meaning they were considered likely to medically improve within 3 years. Twenty-five percent (over 6,000) of these pending CDRs were for children deemed medically expected to improve within 6 to 18 months of their initial determination (see fig.). Of these cases, GAO identified nine recipients who were expected to medically improve but whose CDR had been pending for 13 years or more. Reviews of children who are expected to medically improve are more productive than reviews of children who are not expected to medically improve because they have a greater likelihood of benefit cessation and thus yield higher cost savings over time. 

Childhood CDRs Pending for at Least 6 Years, by Anticipated Medical Improvement Category, for Children with Mental Impairments, as of August 1, 2011

Childhood CDRs Pending for at Least 6 Years, by Anticipated Medical Improvement Category, for Children with Mental Impairments, as of August 1, 2011

Note: Percentages do not equal 100 percent due to rounding. Time frames for when SSA should conduct a CDR are set by state disability determination services staff and are based on the likelihood of a recipient’s medical improvement.

SSA officials report that the agency has placed a higher priority on conducting CDRs for recipients of DI—the agency’s other disability program—although our analysis of SSA data shows that children’s SSI benefits are more likely to be ceased after review.[5] Specifically, SSA officials told us that it is more cost-effective to conduct adult DI CDRs than childhood SSI CDRs, because ceasing benefits for a young adult DI recipient may potentially represent decades of saved benefits. Additionally, because DI benefit payments are, on average, almost twice as much as SSI childhood payments, SSA officials told us that CDRs of adult DI cases generally produce greater lifetime savings. SSA reported that it ceased about 12 percent of all adult DI claims that received a CDR. However, GAO’s analysis of SSA’s data showed that 32 percent of child SSI claims that received a CDR were ceased in fiscal year 2011. For example, of those childhood CDRs conducted for children under age 18 with mental impairments, SSA ceased benefits for about 28 percent on average in fiscal year 2011, with personality disorders and speech and language delay having the highest cessation rates, 39 percent and 38 percent, respectively.[6] Despite these high cessation rates, SSA and state disability determination services officials have acknowledged that the agency has not conducted reviews for child recipients in a timely manner. If these reviews are not conducted in sufficient numbers, the agency will continue to struggle to contain growth in benefit payments, placing added burden on already strained federal resources.



[1] Under Title XVI of the Social Security Act, SSA is generally required to (1) conduct a CDR at least every 3 years on all child recipients under age 18 whose impairments are likely to improve (or, at the Commissioner’s option, recipients whose impairments are unlikely to improve) (42 U.S.C. § 1382c(a)(3)(H)(ii)(I)); (2) conduct a CDR within 12 months after the birth of a child who was granted benefits in part because of low birth weight (42 U.S.C. § 1382c(a)(3)(H)(iv)); and (3) redetermine, within 1 year of the individual’s 18th birthday (or whenever the Commissioner determines the individual is subject to a redetermination), the eligibility of any individual who was eligible for SSI childhood payments in the month before attaining age 18, by applying the criteria used in determining initial eligibility for adults (42 U.S.C. § 1382c(a)(3)(H)(iii)).

[2] In January 2014, SSA reported that it was behind schedule in assessing the continued eligibility of all Disability Insurance (DI) and SSI recipients and had accumulated a backlog of 1.3 million CDRs.

[3] Although SSA is responsible for administering these programs, initial determinations of disability are generally made by state agencies, known as disability determination services offices. In general, disability determination services staff consider the likelihood of a recipient’s medical improvement when setting the time frame for when SSA should conduct a CDR based on authorized time frames specified in the Social Security Act and SSA regulations. Improvement categories and general CDR time frames are (1) “medical improvement expected,” 6 to 18 months; (2) “medical improvement possible,” 3 years; and (3) “medical improvement not expected,” 5 to 7 years.

[4] A total of about 861,000 child recipients with mental impairments were receiving SSI benefits as of December 2011.

[5] DI provides monthly cash benefits to eligible individuals unable to work because of a long-term disability and who meet certain work requirements, whereas SSI provides monthly cash benefits to people with disabilities on the basis of need, regardless of their work history.

[6] The cessation rates cited in this paragraph reflect “initial cessations,” meaning that the agency concluded at the end of the CDR that the claimant involved no longer met the eligibility standards to continue receiving benefits, and therefore started the process to cease benefits. Claimants may have subsequently availed themselves of an appeals process, which could have resulted in a reversal of the initial cessation.

Actions Needed

GAO recommended in June 2012 that the Commissioner of Social Security

  • Direct the Deputy Commissioner of Quality Performance to eliminate the existing CDR backlog of cases for children with impairments who are likely to improve and, on an ongoing basis, conduct CDRs at least every 3 years for all children with impairments who are likely to improve, as resources are made available for these purposes.

If this recommendation were implemented, SSA could potentially save $3.1 billion over 5 years by preventing overpayments to children with mental impairments, according to GAO’s analysis of fiscal year 2011 data.[1] This recommendation would also likely result in additional cost savings from preventing overpayments to children with physical impairments, which are not accounted for in the estimate. SSA’s Office of the Inspector General and SSA have also estimated savings that could be achieved from conducting CDRs. In September 2011, SSA’s Office of the Inspector General estimated that SSA had paid about $1.4 billion in SSI benefits to approximately 513,000 recipients under age 18 who should have not received them—some of whom had been pending reviews for 5 or more years.The Inspector General estimated that SSA will continue to make improper payments of approximately $461.6 million annually until these reviews are completed. Furthermore, SSA estimates a net program savings of about $9, on average, for every $1 invested in conducting CDRs.



[1] To perform this analysis, GAO considered two potential sources of cost savings: (1) addressing the CDR backlog for children with mental impairments who are expected to medically improve or for whom medical improvement is possible and (2) conducting future CDRs for these recipients, as scheduled. We considered such factors as the average cessation rate after appeals, average benefit amount, average amount of time in benefit receipt before age 18, and average cost of performing a CDR.

How GAO Conducted Its Work

The information contained in this analysis is based on findings from the products in the related GAO products section and additional work GAO conducted. For the June 2012 report, GAO interviewed SSA officials; reviewed relevant federal laws, regulations, and guidance; and analyzed SSA data on CDRs conducted from fiscal years 2000 to 2011. For the April 2014 testimony, GAO reviewed SSA data from March and April 2014. To estimate potential cost savings, GAO used fiscal year 2011 data to estimate the savings that could be realized from (1) addressing the CDR backlog for children with mental impairments who are expected to medically improve or for whom medical improvement is possible and (2) conducting future CDRs for these recipients, as scheduled.

Table 16 in appendix V lists the program GAO identified that might have opportunities for cost savings.

Agency Comments & GAO Contact

In commenting on the June 2012 report on which this analysis is based, SSA generally agreed that it should complete more CDRs for SSI children but emphasized that it is constrained by limited funding and competing workloads. Moving forward, one of the goals in SSA’s Fiscal Year 2014-2018 Strategic Plan is to strengthen the integrity of the agency’s programs. In line with this goal, SSA requested additional program integrity funding for fiscal year 2015 to enable the agency to conduct more CDRs, and Congress made these funds available. While additional funding may help address the CDR backlog, GAO continues to have concerns about the agency’s ability to manage its resources in a manner that adequately balances its service delivery priorities with its stewardship responsibility. Because SSA has noted that it considers SSI childhood CDRs to be a lower priority than other CDRs, it is unclear whether the agency will use new increases in funding to review children most likely to medically improve—reviews that could yield a high return on investment.

GAO provided a draft of this report section to SSA for review and comment. SSA provided technical comments, which were incorporated as appropriate.

For additional information about this area, contact Daniel Bertoni at (202) 512-7215 or bertonid@gao.gov.