Medical Insurance &
Social Security for Children Age 18 or Younger
See Transition to Adulthood of this Guide for information about Social Security for Age 18 and older.
Social Security benefits can help families who suffer a loss in income because of their child's health condition. For example, if one parent takes an extended leave of absence from work or resigns to assist with the child's illnesses, physician visits, therapies, medical procedures, and hospitalizations. In addition, the family may have additional expenses related to the child's care that are not covered by medical insurance, such as parking, modifications to the home, and specially adapted toys. Although Social Security benefits cannot cover all of these losses, they can alleviate the impact.
The Social Security Administration (SSA) has nine offices in Allegheny County. To find a nearby location, call 800-772-1213 (national toll-free number), TTY 800-325-0778, or visit www.socialsecurity.gov.
How Social Security Determines If a Child is "Disabled"
To determine if a child is disabled, a Social Security disability evaluation specialist checks to see if the child's disability is listed in specific regulations. These listings are descriptions of symptoms, signs, or laboratory findings of physical and mental problems, such as cerebral palsy, mental retardation, or muscular dystrophy, that are severe enough to disable a child.
If a disability cannot be established using the listing criteria, then a disability evaluation team assesses the child's ability to function in everyday life. Taken into account are reports from parents, physicians, teachers, therapists and other professionals. If the team is unable to make a decision based on these reports, it may ask the parent to take the child for a special examination paid for by the SSA.
The disability evaluation process generally takes several months. In cases of severe disabilities and very limited parental income and assets, benefits can be received while the formal disability decision is being made.
Supplemental Security Income (SSI)
Supplemental Security Income (SSI) benefits are monthly benefits payable to children under the age of 18 years who have disabilities, limited income and assets, or come from a home with limited income and assets. Children also must meet the Social Security Administration’s (SSA) definition of disability.
Most children under the age of 18 do not have their own income or many assets. When children live at home, however, or are away at school but return home occasionally and are subject to parental control, SSA considers the parents' income and assets.
For disability purposes in the SSI program, a child becomes an adult at age 18. If your child is already receiving SSI payments, SSA reviews the child’s medical condition when he or she turns age 18. SSA usually does this review during the one-year period that begins on your child’s 18th birthday. SSA will use the adult disability rules to decide whether your 18-year-old is disabled.
If your child was not eligible for SSI before his or her 18th birthday because you and/or your spouse had too much income or resources, he or she may become eligible for SSI at age 18.
SSA uses different medical and non-medical rules when deciding if an adult can get SSI disability payments. For example, the SSA does not count the income and assets of family members when deciding whether an adult meets the financial limits. The SSA counts only the adult’s income and resources and that of a spouse, if any.
Social Security Disability Insurance (SSDI)
There are two ways to obtain SSDI:
- 1. Social Security Dependents Benefits
These are benefits payable to children under age 18 (dependents) of a parent who is collecting retirement or disability benefits from the SSA, or a parent who has died. A child can receive these benefits until age 18 (age 19 if he or she is a full-time student who has not yet graduated from high school). If the child has a disability, eligibility for benefits continues. SSA makes the disability decision using the disability rules for adults
- 2. Social Security Benefits for Adults Disabled Since Childhood
The SSDI program pays benefits to adults who have a disability that began before they became 22 years old. SSA considers this SSDI benefit as a “child’s” benefit because it is paid on a parent’s Social Security earnings record. The applicant must be unmarried. For a disabled adult to become entitled to this “child” benefit, one of his or her parents:
- Must be receiving Social Security retirement or disability benefits; or
- Must have died and have worked long enough under Social Security.
SSDI disabled adult “child” benefits continue as long as the individual remains disabled. Your child does not need to have worked to get these benefits.
How To Apply
Call your local Social Security office to schedule an interview (call 800-772-1213, TTY 800-325-0778, or visit www.socialsecurity.gov to identify the office nearest you)
Be prepared to answer questions as specifically and thoroughly as possible at the interview. Have the following documents and information ready:
- Child's Social Security number and original birth certificate (not a photocopy).
- Records that show your income and assets, and your child's income and assets (e.g., tax returns; pay stubs; insurance policies; all statements showing interest income from savings accounts; certificates of deposits (CDs); IRAs; and other investments).
- Medical records for your child or the address where they can be obtained. Bring names, addresses, and phone numbers of physicians, hospitals, clinics, and specialists your child has visited, and dates of visits to physicians and hospitals.
- Be prepared to explain how your child's disability affects his or her everyday life at home, school and elsewhere.
- Names, addresses, and phone numbers of individuals who have observed how your child functions in everyday life (e.g., teachers, day care providers, family members).
- Copies of your child's school records.
Continuing Disability Reviews (CDRs)
Once a child starts receiving SSI or SSDI, the law requires SSA to review your child’s medical condition from time to time to verify that he or she is still disabled. This review must be done:
- At least every three years for children younger than age 18 whose conditions are expected to improve; and
- By age 1 for babies who are getting SSI payments because of their low birth weight. If SSA determines that the child’s medical condition is not expected to improve by their first birthday, the review will be scheduled for a later date.
SSA may perform a disability review even if your child’s condition is not expected to improve. When SSA does a review, you must present evidence that your child is and has been receiving treatment that is considered medically necessary for his/her medical condition.
Denial of Benefits
If you are denied SSI or SSDI benefits, you may request a reconsideration by letter or by completing an appeal form (SSA-561), which can be obtained at your local SSI office or at www.ssa.gov/online/ssa-561.html. (This form is also referred to as SSA-561-U2.) You have the right to submit this form even if your SSA representative discourages it. If the benefit decision is reversed, you will be paid retroactively to the date you first applied.
If you disagree with the initial denial, you may ask for a hearing on the “disability” issues of your claim, such as whether your child is disabled, when the disability began or whether it has ended.
An administrative law judge - who had no part in the first decision about your case - will conduct the hearing. You and your representative, if you have one, may come to the hearing and explain your case in person. You may look at the information in your file and give new information. The administrative law judge will question you and any witnesses at the hearing. You or your representative also may question the witnesses.
It is usually to your advantage to attend the hearing. If you do not wish to do so, you must tell the Social Security Administration in writing that you do not want to attend. Unless the administrative law judge believes your presence is needed to decide the case, he or she will make a decision based on all the information in your case, including any new information given. After the hearing, the administrative law judge will send you a letter and a copy of the administrative law judge’s decision.
Many people handle their own Social Security appeals with free help from Social Security. But you can choose a lawyer, a friend or someone else to help you. Someone you appoint to help you is called your “representative.” SSA will work with your representative just as SSA staff would work with you. Your representative can act for you in most Social Security matters and will receive a copy of any decisions SSA makes about your claim. Your representative cannot charge or collect a fee from you without first getting written approval from Social Security. If you want more information about having a representative, contact the Social Security Administration at 800-772-1213 (national toll-free number) or download Your Right To Representation (Publication No. 05-10075).