new opportunities for soar in south dakota · 2016-11-18 · • sections e. and f. have more...

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10/19/2016

SAMHSA SOAR Technical Assistance Center

The CURRENT listings for evaluating mental disorders are 30 years old.

The medical criteria in the REVISED listings reflect the diagnostic criteria for mental disorders in the current version of the Diagnostic and Statistical Manual, the DSM-5, which is the standard classification of mental disorders used by mental health professionals in the United States.

The CURRENT medical criteria are based on the diagnostic criteria in the DSM-III, the edition of the DSM available at that time.

To serve individuals in need, it is essential that our criteria for evaluating mental disorders are consistent with current medical standards and care practices.

When drafting the REVISED rules, we considered:

• The medical community’s understanding of mental disorders,

• Feedback from professional organizations, advocacy groups, and the public, and

• Our program experience.

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Now, for a brief overview of the rulemaking history.

• The revised rules are the culmination of a continuous, connected process that started with our Advance Notice of Proposed Rulemaking, published in 2003.

• In the time before and after the publications of the Advance Notice of Proposed Rulemaking and the Notice of Proposed Rulemaking in 2010, we engaged with advocacy groups, medical professionals, and the public on our proposed policies.

• We published the final rule on September 26, 2016.

• We delayed its effective date from our usual “60 days after publication” to give us

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time to update our systems, provide training and guidance to all of our adjudicators, and revise our internal forms and operating instructions before we implement the revised rules.

• The revised rules will be effective on January 17, 2017.

• We will apply the revised rules to NEW applications filed on or after the effective date, and to claims that are PENDING on or after the effective date.

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As you may already know, we use a five-step sequential evaluation process to determine whether an adult is disabled.

At Step 1, we consider an individual’s work activity.

At Step 2, we consider the severity of the individual’s impairment or combination of impairments.

At Step 3, we also consider the severity of the individual’s impairment when we determine whether the impairment meets or medically equals a listing. We do not deny claims at Step 3.

If we do not allow the claim at Step 3 using the listings, we continue on to Steps 4 and 5 of the sequential evaluation process.

At these steps, we consider the individual’s age, education, and work experience, and

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he or she may qualify for benefits at Step 5.

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All of the mental disorders listings, except 12.05, have a similar structure.

Paragraph A includes MEDICAL criteria.

Paragraph B includes FUNCTIONAL criteria.

And, Paragraph C, which is in listings 12.02, 12.03, 12.04, 12.06, and 12.15, includes ALTERNATIVE functional criteria.

In order to meet a listing, a person’s mental disorder must satisfy the paragraph A and B criteria or, for those listings with paragraph C criteria, the mental disorder must satisfy the paragraph A and C criteria.

The only exception to this is listing 12.05, which I will discuss a little later.

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The MEDICAL criteria in Paragraph A are based on the updated diagnostic criteria for mental disorders in the DSM-5.

The titles of the listings are also updated to reflect the terminology in the DSM-5.

Note that the numbered listings reflect many of the diagnostic CATEGORIES from the DSM-5 with the exception of listing 12.05, intellectual disorder, which is not a diagnostic CATEGORY from the DSM-5.

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• Each listing contains the Paragraph B FUNCTIONAL criteria.

• We use these criteria to evaluate the SEVERITY of an individual’s mental disorder.

• We will use the CURRENT Paragraph B criteria, which are (1) activities of daily living, or ADLs, (2) social functioning, (3) concentration, persistence, or pace, and (4) episodes of decompensation, through January 16, 2017.

• We will being using the REVISED Paragraph B criteria on January 17, 2017.

• The revised criteria are: (1) understand, remember, or apply information, (2) interact with others, (3) concentrate, persist, or maintain pace, and (4) adapt or manage oneself.

• We also refer to these criteria as the AREAS of MENTAL functioning an individual uses in a WORK setting.

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• While ADLs will no longer be one of our listing CRITERIA, ADLs will continue to play an important role in our program as a TYPE of information.

• We will continue to use information about how an individual performs his or her ADLs in order to infer how he or she would be able to use his or her areas of mental functioning in a work setting, keeping in mind that the demands of a work setting are different from the person’s home setting.

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• The revised rules provide DEFINITIONS for the five points of the rating scale that adjudicators use to rate the DEGREE of limitation an individual has using his or her Paragraph B areas of mental functioning.

• The definitions are:

• No limitation, or none. The individual IS ABLE to function in this area independently, appropriately, effectively, and on a sustained basis.

• Mild limitation. The individual’s functioning in this area independently, appropriately, effectively, and on a sustained basis is SLIGHTLY LIMITED.

• Moderate limitation. The individual’s functioning in this area independently, appropriately, effectively, and on a sustained basis is FAIR.

• Marked limitation. The individual’s functioning in this area independently,

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appropriately, effectively, and on a sustained basis is SERIOUSLY LIMITED.

• And finally, EXTREME limitation. The individual is NOT ABLE to function in this area independently, appropriately, effectively, and on a sustained basis.

• Although the definition of EXTREME limitation states that the individual would not be able to function in the given area, our policy continues to be that extreme limitation does not necessarily mean a total lack or loss of ability to function.

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• We use the Paragraph C criteria, which are alternative functional criteria, to evaluate SERIOUS and PERSISTENT mental disorders.

• The introductory statement in Paragraph C requires a medically documented history of the EXISTENCE of the disorder over a period of at least two years.

• Sub-paragraph C1 requires that the individual receives ONGOING medical treatment, mental health therapy, psychosocial supports, or a highly structured setting that DIMINISHES the symptoms or signs of his or her mental disorder.

• Sub-paragraph C2 requires that, despite the diminished symptoms and signs of the mental disorder, the individual has achieved only MARGINAL adjustment.

• The intent of the paragraph C criteria is to identify individuals who now appear stable ONLY because they rely on significant supports in order to function day to day.

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• When an individual, who previously had impaired functioning due to his or her mental disorder, appears to NOW have relatively stable baseline functioning, we may not identify that his or her mental disorder satisfies the Paragraph B criteria.

• However, if we would expect such an individual’s functioning to decline if his or her supports for daily functioning were no longer available, or if he or she were put into a more challenging or demanding situation, such as in a competitive workplace, then we can find that his or her mental disorder satisfies the Paragraph C criteria.

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• The revised rules reorganize and simplify listings 12.05 and 112.05, intellectual disorder.

• The new listing criteria closely match the diagnostic criteria for intellectual disability in the DSM-5 and the definition of intellectual disability from the American Association on Intellectual and Developmental Disabilities.

• The listings contain only a Paragraph A and a Paragraph B.• We use 12.05 A and 112.05 A when an individual has INTELLECTUAL

DISABILITY but is UNABLE to take a standardized intelligence test.• We use 12.05 B and 112.05 B when an individual has INTELLECTUAL

DISABILITY and IS ABLE to take a standardized intelligence test.

• An introductory text section, 12.00 H, includes comprehensive guidelines for applying listing 12.05.

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The REVISED rules include NEW listings.

• Listings 12.11 and 112.11 – for Neurodevelopmental Disorders

• Listings 12.13 and 112.13 – for Eating Disorders

• Listings 12.15 and 112.15 – for Trauma- and Stressor-Related Disorders

• And listing 112.14 – for Developmental Disorders in Infants and Toddlers

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• The Psychiatric Review Technique, or PRT, is the term we use to describe our PROCESS of evaluating mental impairments in adults at Steps two and three of the sequential evaluation process.

• The PRT involves using the five-point rating scale to rate the degree of limitation a person has using the four areas of mental functioning or the Paragraph B criteria

• At Step 2, we use the four areas of mental functioning and the rating scale to help us assess if an adult’s mental impairment is severe

• At Step 3, we use the four areas of mental functioning and the rating scale to help us assess if an adult’s mental impairment meets or medically equals a listing

• We only use the PRT for ADULT claims involving MENTAL impairments.

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• The PRT – both the paper and electronic formats of the technique – will be revised to be consistent with the revised listings.

• The PRT policies have not changed.

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Now, I’ll quickly describe the content in some sections of the introductory text for the listings.

Section 12.00 A:

• Names the listings

• Describes the paragraph A, B, and C criteria

• Explains how the listings are met

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Section 12.00 B:

• Contains 11 numbered sections – one section for each listing

• Provides information about the disorders we evaluate under each listing

• Includes examples of diagnoses

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Section 12.00 C:

• Provides examples of sources of evidence

• Explains the value of longitudinal evidence

• Discusses how we evaluate claims that do not have longitudinal evidence

• Explains how to evaluate evidence about how people function in unfamiliar settings or supported situations

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• Section D. provides guidance on how to evaluate the effects of an individual’s mental disorder when he or she is receiving a lot of support or treatment.

• Sections E. and F. have more guidance about the Paragraph B criteria and how to evaluate an individual’s limitations.

• Section G includes more guidance about the Paragraph C criteria that appear in listings 12.02, 12.03, 12.04, 12.06, and 12.15

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Now, to wrap up my presentation, I’ll give you a quick summary of the revised rules:

The rules:

• Are consistent with the current version of the DSM, which is the DSM-5,

• They update the criteria we use to evaluate the effects of mental disorders on the ability to function in daily life and in work settings.

• And, in general, the revised rules reflect current diagnostic standards, terminology, and clinical attitudes toward mental health disorders.

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The revised rules also:

• Recognize that individuals who experience chronic homelessness may have difficulty obtaining supporting medical evidence, and the rules identify non-medical sources of evidence.

• The rules articulate how the support an individual receives—for example, help from family—may falsely present the individual as having more abilities and independence than in reality.

What we see in the disability program is downstream of what happens in clinical practice.

The outside world and medical treatments have evolved and changed, and our revised rules will be up to date with those trends.

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• You can help the applicant complete the SSA-3380-BK form, which is the “Function Report – Adult – Third Party,” when an individual receives the FORM from the Disability Determination Services, or DDS

• You can help the applicant obtain copies of medical records, especially mental health counseling records.

• And, you can help the applicant stay in contact with staff at the state DDS office and respond to requests—for information, records, etc.—from that office.

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Tip: It is helpful to walk through this example, to illustrate how an ADL task can fit into each of the four areas of functioning.

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new opportunities for soar in south dakota · 2016-11-18 · • sections e. and f. have more...

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