Understanding SSA’s Policy on Drug Addiction and Alcoholism The webinar will begin shortly. Audio:...

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 CouncilThis 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 EdgingtonNational Health Care for the Homeless Council

Kristin LupferSAMHSA SOAR TA Center Policy Research Associates, Inc.

Webinar Instructions Question instructions Muting Recording availability Downloading documents Evaluation

AgendaWelcome 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.

Evaluating Evaluating Cases Involving Cases Involving Drug Addiction Drug Addiction and Alcoholismand Alcoholism(DAA)(DAA)

Presenter:Presenter:Michele SchaeferMichele Schaefer

Evaluating Evaluating Cases Involving Cases Involving Drug Addiction Drug Addiction and Alcoholismand Alcoholism(DAA)(DAA)

Presenter:Presenter:Michele SchaeferMichele Schaefer

13-2p:

1996 Legislative Change1996 Legislative ChangePublic Law 104-121Public Law 104-121

1996 Legislative Change1996 Legislative ChangePublic Law 104-121Public Law 104-121

A claimant shall not be considered A claimant shall not be considered disabled if drug addiction or disabled if drug addiction or

alcoholism is a contributing factor alcoholism is a contributing factor material to the determination that material to the determination that

the individual is disabled.the individual is disabled.

DAA Social Security DAA Social Security Ruling 13-2pRuling 13-2p

DAA Social Security DAA Social Security Ruling 13-2pRuling 13-2p

SSR 13-2p; Titles II and XVI: SSR 13-2p; Titles II and XVI: Evaluating Cases Involving Drug Evaluating Cases Involving Drug Addiction and Alcoholism (DAA)Addiction and Alcoholism (DAA)

Published on February 20, 2013Published on February 20, 2013

Effective March 22, 2013Effective March 22, 2013

DAA Social Security DAA Social Security Ruling 13-2p, Cont.Ruling 13-2p, Cont.

DAA Social Security DAA Social Security Ruling 13-2p, Cont.Ruling 13-2p, Cont.

DAA SSR explains how we consider DAA SSR explains how we consider whether DAA is materialwhether DAA is material

15 Questions in the SSR15 Questions in the SSR

6-Step DAA Evaluation Process6-Step DAA Evaluation Process

DAA DefinitionDAA DefinitionDAA DefinitionDAA Definition

We define DAA as We define DAA as “Substance Use Disorders”“Substance Use Disorders”

DAA DAA Does Not Does Not Include:Include:DAA DAA Does Not Does Not Include:Include:

Caffeine and nicotine disordersCaffeine and nicotine disorders

Use of prescription medications taken Use of prescription medications taken as as prescribedprescribed

Children who have medical conditions Children who have medical conditions resulting from their mothers’ use of drugs resulting from their mothers’ use of drugs or alcohol during pregnancyor alcohol during pregnancy

Occasional misuse of drugs Occasional misuse of drugs or alcoholor alcohol

Substance-induced disorders Substance-induced disorders are notare not included in our included in our

definition of DAA.definition of DAA.

Substance-induced disorders Substance-induced disorders are notare not included in our included in our

definition of DAA.definition of DAA.

Exceptions:Exceptions:– Substance-Induced Persisting DementiaSubstance-Induced Persisting Dementia

– Substance-Induced Persisting Amnestic Substance-Induced Persisting Amnestic DisorderDisorder

DAA and Sequential DAA and Sequential EvaluationEvaluation

DAA and Sequential DAA and Sequential EvaluationEvaluation

Adjudicators apply the sequential Adjudicators apply the sequential evaluation twice:evaluation twice:

– Once to determine that the claimant is Once to determine that the claimant is disabled considering all impairmentsdisabled considering all impairments

– Second evaluation to determine whether Second evaluation to determine whether the claimant would still be disabled if he the claimant would still be disabled if he or she were not using drugs or alcoholor she were not using drugs or alcohol

Burden of proofBurden of proofBurden of proofBurden of proof

The burden of proving disability The burden of proving disability throughout the sequential throughout the sequential evaluation process rests with the evaluation process rests with the claimant. claimant.

If DAA IS Material, then the If DAA IS Material, then the Claimant IS NOT DisabledClaimant IS NOT Disabled

DAA is Material When: DAA is Material When: DAA is Material When: DAA is Material When:

The claimant’s only impairment is The claimant’s only impairment is substance abuse or dependence; orsubstance abuse or dependence; or

The claimant’s other physical or mental The claimant’s other physical or mental impairment is, by itself, not disabling. impairment is, by itself, not disabling. For example, the claimant has a hearing For example, the claimant has a hearing impairment that’s not severe.impairment that’s not severe.

If DAA is NOT Material, then If DAA is NOT Material, then the Claimant IS Disabledthe Claimant IS Disabled

DAA is NOT Material DAA is NOT Material When: When:

DAA is NOT Material DAA is NOT Material When: When:

Claimant has impairment(s) that is NOT Claimant has impairment(s) that is NOT affected by the DAA and is disabled; oraffected by the DAA and is disabled; or

Claimant has physical impairment(s) that is Claimant has physical impairment(s) that is NOT affected by DAA, AND the vocational NOT affected by DAA, AND the vocational grid rules direct a finding of disabled; orgrid rules direct a finding of disabled; or

Claimant has a permanent condition that Claimant has a permanent condition that resulted from drinking or taking drugs and it resulted from drinking or taking drugs and it is a SEPARATE impairmentis a SEPARATE impairment

DAA Evaluation Process DAA Evaluation Process Step 1Step 1


Does the claimant have DAA?Does the claimant have DAA?



Is the claimant disabled Is the claimant disabled considering all impairments, considering all impairments,

including DAA?including DAA?



Is DAA the only impairment? Is DAA the only impairment? – If DAA is the claimant’s only impairment, If DAA is the claimant’s only impairment,

DAA is material and a denial is DAA is material and a denial is appropriateappropriate



Is the other impairment(s) disabling by Is the other impairment(s) disabling by itself while the claimant is dependent itself while the claimant is dependent upon or abusing drugs or alcohol?upon or abusing drugs or alcohol?– If the other impairment(s) is NOT If the other impairment(s) is NOT

disabling by itself, DAA is material and disabling by itself, DAA is material and a denial is appropriatea denial is appropriate

– If the other impairment(s) IS disabling If the other impairment(s) IS disabling by itself, go to Step 5by itself, go to Step 5



Does the DAA cause or affect the Does the DAA cause or affect the claimant’s medically determinable claimant’s medically determinable impairment(s)?impairment(s)?

– If DAA is not causing or does not affect If DAA is not causing or does not affect the other impairment, DAA is NOT the other impairment, DAA is NOT material. An allowance is appropriate. material. An allowance is appropriate.

Step 5 Scenarios for Establishing Step 5 Scenarios for Establishing that DAA Does NOT Cause or Affect that DAA Does NOT Cause or Affect

the Other Impairments:the Other Impairments:

Step 5 Scenarios for Establishing Step 5 Scenarios for Establishing that DAA Does NOT Cause or Affect that DAA Does NOT Cause or Affect

the Other Impairments:the Other Impairments:

Other disabling impairment has no Other disabling impairment has no relationship to the DAArelationship to the DAA

Claimant acquired a separate disabling Claimant acquired a separate disabling impairment while using a substanceimpairment while using a substance

DAA medically caused the other disabling DAA medically caused the other disabling impairment BUT other impairment is impairment BUT other impairment is irreversible or could not improve to the point irreversible or could not improve to the point of nondisabilityof nondisability

DAA Evaluation Process DAA Evaluation Process Step 5 Cont’dStep 5 Cont’d

DAA Evaluation Process DAA Evaluation Process Step 5 Cont’dStep 5 Cont’d

If DAA does not cause or affect other If DAA does not cause or affect other impairments to be found non-impairments to be found non-disabling, DAA is NOT material and an disabling, DAA is NOT material and an allowance is appropriateallowance is appropriate

If DAA causes or affects the claimant’s If DAA causes or affects the claimant’s other medically determinable other medically determinable impairment(s), proceed to step 6.impairment(s), proceed to step 6.



Would the other impairment(s) Would the other impairment(s) improve to the point of nondisability improve to the point of nondisability in the absence of DAA?in the absence of DAA?

– Yes, DAA is material and a denial is Yes, DAA is material and a denial is appropriateappropriate

– No, DAA is not material and a allowance No, DAA is not material and a allowance is appropriateis appropriate

Question 14 -What explanation does Question 14 -What explanation does the determination or decision need the determination or decision need

to contain? to contain?

Question 14 -What explanation does Question 14 -What explanation does the determination or decision need the determination or decision need

to contain? to contain?

Findings:Findings:

1.1. Claimant has DAAClaimant has DAA

2.2. Claimant is disabled considering all Claimant is disabled considering all impairments (including DAA)impairments (including DAA)

3.3. Claimant would or would not be Claimant would or would not be disabled in the absence of DAAdisabled in the absence of DAA

Implications for DDS and Recommendations for Providers

Daette QuickCertified 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, LSWSAMHSA SOAR Technical Assistance Center


SOAR: An Active RoleSOAR 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


For More Information

SAMHSA SOAR TA Center

www.prainc.com/soar

National Health Care for the Homeless Council

www.nhchc.org

http://www.prainc.com/soar

http://www.nhchc.org/

Understanding SSA’s Policy on Drug Addiction and Alcoholism The webinar will begin shortly. Audio:...

Documents

Transcript of Understanding SSA’s Policy on Drug Addiction and Alcoholism The webinar will begin shortly. Audio:...