Procedural Standard 03-1
November 10, 2011
Purpose:
TO:
All DES Staff
FR:
A. E. Adams, Ph.D. Director, Disability Evaluation Services
BY:
Sherry Campanelli, Program Compliance Manager
RE:
Evaluation of Disability on the Basis of Mental Disorders
This Procedural Standard provides an overview of MassHealth and Department
of Transitional Assistance (DTA) program requirements for the evaluation of
disability on the basis of mental disorders.
Background: Disability Evaluation Services (DES) uses federal Supplemental Security
Income (SSI) Listings of Impairments 12.00ff. as well as the Social Security
Administration Program Operations Manual System (POMS) reference DI
34001.032 as the authoritative basis for development and evaluation of mental
impairments. DES uses Code of Massachusetts Regulations 106 CMR 320.210
and 106 CMR 203.540 to develop and evaluate mental disability for the
Emergency Aid to the Elderly, Disabled and Children (EAEDC) and
Transitional Aid to Families with Dependent Children (TAFDC) programs
administered by DTA. The purpose of this procedural standard is to provide
guidance regarding how to apply these instructions in the context of the DES
consolidated review process. It is the reviewer’s responsibility to be familiar
with the full text of these references.
Process:
Case Development
A Disability Assistant (DA) routinely requests information from all mental
health treating sources within the past 12 months in order to meet the need for
medical evidence.
The Disability Reviewer (DR) is also cognizant of the requirements of SSI
Listings 12.02 C, 12.03 C and 12.04 C for a two-year medically documented
history of mental disorder. It is necessary on occasion, depending on the facts
of the case, to utilize information from prior disability applications and/or to
develop a full two-year history of mental impairment in order to assure that an
1
Revision #2. Supersedes PS 03-01 “Evaluation of Disability on the Basis of Mental Disorders” dated
February 26, 2003 and January 22, 2007.
applicant receives full consideration under the SSI listings. If the client alleges
mental retardation, traumatic brain injury or learning disabilities, treating
sources that have been seen prior to 12 months prior to the disability
applications may be contacted to obtain psychological test results. The DR is
responsible to identify the need for development of a greater than 12 month
medical history throughout the disability review process.
Medical evidence is also needed to establish a medically determinable mental
impairment of the required severity and duration (12 or more months for
MassHealth, a minimum of 60 days for EAEDC and 30 days for TAFDC) based
on symptoms (the client’s own description of the mental impairment), signs
(medically demonstrable phenomena that indicate specific psychological
abnormalities, e.g., abnormalities of behavior, mood, thought, memory,
orientation, development, or perception, as described by an appropriate medical
source) and laboratory findings (psychological test results).
When the client’s medical records have not been received within 28 days, the
DES review process provides for routine follow-up contacts with treating
source(s) by telephone call/fax unless the source specifically objects to followup contacts or is otherwise consistently uncooperative (does not respond to
requests for any client.)
When clinical information is unavailable due to the client’s lack of a treating
source or no medical records have been received, or the medical records
received are insufficient for a determination, the DR requests a psychological or
psychiatric consultative examination.1 Psychological testing is requested as part
of a psychological CE, as appropriate (see current CE Request Format).
“A CE to assess mental impairment(s) will include a comprehensive mental
status examination which generally is comprised of a narrative description of
the client’s appearance, behavior, and speech; thought processes (e.g., loosening
of associations); thought content (e.g., delusions); perceptual abnormalities
(e.g., hallucinations); mood and affect (e.g., depression, mania); sensorium and
cognition (e.g., orientation, recall, memory, concentration, fund of information,
and intelligence) and judgment and insight. The individual case facts determine
the specific areas of mental status that need to be emphasized during the
examination.”
For DTA originated cases, if both medical and psychological CE’s are needed, first request the type
of CE associated with the client’s primary claim of disability. Request both CE’s simultaneously if
the primary claim cannot be ascertained. If the first CE does not result in approval, obtain the second
CE.
2
Revision #2. Supersedes PS 03-01 “Evaluation of Disability on the Basis of Mental Disorders” dated
February 26, 2003 and January 22, 2007.
1
Disability Review:
The reviewer assesses the clinical record(s) to:

Identify the client’s medically determinable mental impairment.

Determine severity (the functional limitation(s) associated with the
medically determinable mental impairment are evaluated and if more
than slight/minimal, Step IIA, severity is met).

Determine duration (has the functional limitation associated with the
medically determined mental impairment lasted or will last 12 months or
result in death for MassHealth, 60 days for EAEDC and 30 days for
TAFDC?).

Select the appropriate SSI Listing/DTA Medical Standard associated
with the medically determinable mental impairment(s).
The following are considerations in the process of disability review:
Subjective information must be supported by objective findings in the mental
status examination and be consistent with clinical documentation in the medical
record(s) or consultative exam report.
Work attempts are evaluated to determine the client’s behavior during any
attempt to work and the circumstances surrounding termination of the work
effort. Any special supports (such as those supplied through supported
employment or transitional employment programs through community mental
health or sheltered workshops) are useful in determining the ability or inability
to function in a work setting.
Individuals with chronic mental impairments who have long histories of
repeated hospitalizations or prolonged outpatient care with supportive therapy
and medication require evaluation for their need for structure in their lives to
minimize stress and reduce their signs and symptoms. Chronic mental
impairments are evaluated to identify whether the client has had repeated
decompensations, a residual disease process that has resulted in marginal
adjustment and decompensation is expected with a minimal increase in mental
demands or change in environment, or there is a current history of inability to
function outside a highly supportive environment.
The following are clarifications related to application of the SSI Listings :
Paragraph A. of the mental listings refers to the symptoms, signs and/or
psychological test results documented by the client’s treating source(s)
3
Revision #2. Supersedes PS 03-01 “Evaluation of Disability on the Basis of Mental Disorders” dated
February 26, 2003 and January 22, 2007.
and/or the consultative examination (not just the subjective symptoms noted
by the client yet unsupported by clinical documentation).
Paragraph B. (Part D. in 12.05/ L5 ) of the mental listings refers to the effect of
the client’s mental signs and symptoms on functional ability as follows:
Activities of daily living (ADLs) include adaptive activities such as cleaning,
shopping, cooking, taking public transportation, paying bills, maintaining a
residence, caring appropriately for grooming and hygiene, using telephones and
directories and using a post office. In the context of the overall situation, the
quality of these activities is assessed by their independence, appropriateness,
effectiveness, and sustainability and by the extent to which the client’s is able to
initiate and participate in activities independent of supervision or direction.
“Marked” restriction of activities of daily living is not defined by a specific number
of ADL’s in which functioning is impaired, but by the nature and overall degree of
interference with function. For example, if a client does a wide range of activities of
daily living, he/she may still be found to have marked limitation in daily activities if
he/she has serious difficulty performing them without direct supervision, or on a
consistent, useful, routine basis, or without undue interruptions or distractions.
Examples of marked restrictions in ADLs may include but, are not limited to, a
pattern (not just one incident) of:
 Living in a supervised living arrangement requiring assistance and/or close
supervision and support to perform ADLs (not due to substance abuse treatment
alone.)
 Living in an institution, including nursing home or hospital.
 Participating in a long-term (6 months or more) partial hospitalization program or
day treatment program.
 Inability to function independently outside the area of one’s home (inability to
shop, bank, use public transportation, use a post office, etc.) Such inability must
be due to a mental impairment not to a physical impairment, language barrier, or
unfamiliarity with the area.
 Inability to perform daily tasks like caring appropriately for grooming and
hygiene, cooking, cleaning, paying bills, using telephones/directories,
maintaining a residence without assistance or supervision due to a mental (not
physical) impairment.
4
Revision #2. Supersedes PS 03-01 “Evaluation of Disability on the Basis of Mental Disorders” dated
February 26, 2003 and January 22, 2007.
 Active involvement with Massachusetts Rehabilitation Commission (MRC),
Department of Mental Health (DMH) and/or Department of Mental Retardation
(DMR) services may be considered. Contact the MRC rehabilitation counselor,
the DMH case manager or the DMR Client Service Coordinator (CSC) for
specific information.
Social functioning refers to the capacity to interact independently,
appropriately, effectively, and on a sustained basis with other individuals.
Social functioning includes the ability to get along with others, such as family
members, friends, neighbors, grocery clerks, landlords, or bus drivers. The
client may demonstrate impaired social functioning by, for example, a history of
altercations, evictions, firings, fear of strangers, avoidance of interpersonal
relationships, or social isolation. The client may exhibit strength in social
functioning by such things as his/her ability to initiate social contacts with
others, communicate clearly with others, or interact and actively participate in
group activities. The DES review also needs to consider cooperative behaviors,
consideration of others, awareness of others’ feelings, and social maturity.
Social functioning in work situations may involve interactions with the public,
responding appropriately to persons in authority (e.g., supervisors), or
cooperative behaviors involving coworkers.
DES review does not define “marked” by a specific number of different
behaviors in which social functioning is impaired, but by the nature and overall
degree of interference with function. For example, if a client is highly
antagonistic, uncooperative, or hostile but is tolerated by local storekeepers,
he/she may nevertheless be found to have a marked limitation in social
functioning because that behavior is not acceptable in other social contexts.
Additional examples of marked difficulties in maintaining social functioning
include but, are not limited to:
 Housebound (documented findings of a pattern, not just one incident, of social
isolation or social withdrawal that is consistent with the inability to leave the
house or maintain contact with family, friends and peers related to mental health
impairment)
 A pattern of frequent conflicts (e.g., fighting, firings, evictions due to behavior)
 Psychotic symptoms (e.g., hallucinations, psychotic paranoia, delusions,
impaired reality testing)
 Preoccupation with symptoms of mental impairment resulting in inability to
relate or socialize with family, friends, peers.
5
Revision #2. Supersedes PS 03-01 “Evaluation of Disability on the Basis of Mental Disorders” dated
February 26, 2003 and January 22, 2007.
 A GAF (Global Assessment of Functioning Scale) of 50 or less as defined in the
current DSM when consistent with and supported by other clinical findings.
“Concentration, persistence, or pace refers to the ability to sustain focused
attention and concentration sufficiently long to permit the timely and
appropriate completion of tasks commonly found in work settings. Limitations
in concentration, persistence, or pace are best observed in work settings, but
may also be reflected by limitations in other settings. In addition, major
limitations in this area can often be assessed through clinical examination or
psychological testing. Wherever possible, however, a mental status
examination should be supported by other available evidence.”
On mental status exam, concentration is assessed by tasks such as having the
client subtract serial sevens or serial threes from 100. In psychological tests of
intelligence or memory, concentration is assessed through tasks requiring shortterm memory or through tasks that must be completed within established time
limits. In work evaluations, concentration, persistence, or pace, is assessed by
testing the client’s ability to sustain work using appropriate production
standards, in either real or simulated work tasks (e.g., filing index cards,
locating telephone numbers, or disassembling and reassembling objects).
Strengths and weaknesses in areas of concentration and attention can be
discussed in terms of the client’s ability to work at a consistent pace for
acceptable periods of time and until a task is completed, and his/her ability to
repeat sequences of action to achieve a goal or an objective. The DES review
must exercise great care in reaching conclusions about the client’s ability or
inability to complete tasks under the stresses of employment during a normal
workday or workweek based upon a time-limited mental status examination or
psychological testing by a clinician, or based on the client’s ability to complete
tasks in other settings that are less demanding, highly structured, or more
supportive. The disability review must evaluate all the evidence, with an
emphasis on how independently, appropriately, and effectively the client is able
to complete tasks on a sustained basis.
DES disability review does not define “marked” by a specific number of tasks
the client is unable to complete, but by the nature and overall degree of
interference with function. The client may be able to sustain attention and
persist at simple tasks but may have difficulty with complicated tasks.
Deficiencies that are apparent only in performing complex procedures or tasks
would not satisfy the intent of the paragraph B. criterion. However, if a client
can complete many simple tasks, he/she may nevertheless be found to have a
marked limitation in concentration, persistence, or pace if he/she cannot
complete these tasks without extra supervision or assistance, or in accordance
with quality and accuracy standards, or at a consistent pace without an
6
Revision #2. Supersedes PS 03-01 “Evaluation of Disability on the Basis of Mental Disorders” dated
February 26, 2003 and January 22, 2007.
unreasonable number and length of rest periods, or without undue interruptions
or distractions.
The SSI Listings require “marked difficulties in maintaining concentration,
persistence, or pace” due to mental impairment.
However, DTA Medical Standards simply require “deficiencies of
concentration, persistence or pace resulting in frequent failure to complete tasks
in a timely manner (in work settings or elsewhere)” due to mental impairment.
Moderate limitations in concentration or pace meet the DTA requirement.
Moderate versus marked limitations in concentration, persistence or pace is
derived from the objective clinical documentation as well as other relevant
information contained in the file. If the DR is uncertain whether the restrictions in
these areas of mental functioning are moderate or marked, it is appropriate to request
a mental Residual Functional Capacity (RFC) assessment by a DES
Psychiatric/Psychological Advisor (PA) in order to adequately make the distinction.
“Episodes of decompensation are exacerbations or temporary increases in
symptoms or signs accompanied by a loss of adaptive functioning, as
manifested by difficulties in performing activities of daily living, maintaining
social relationships, or maintaining concentration, persistence, or pace.
Episodes of decompensation may be demonstrated by an exacerbation of
symptoms or signs that would ordinarily require increased treatment or a less
stressful situation (or a combination of the two). Episodes of decompensation
may be inferred from medical records showing significant alteration in
medication; or documentation of the need for a more structured psychological
support system (e.g., hospitalizations, placement in a half-way house, or a
highly structured and directing household); or other relevant information in the
record about the existence, severity, and duration of the episode.”
The term repeated episodes of deterioration, each of extended duration in these
listings means three episodes within one year, or an average of once every four
months, each lasting at least 2 weeks. If a client has experienced more frequent
episodes of shorter duration or less frequent episodes of longer duration are
experienced, the disability reviewer must use judgment to determine if the duration
and functional effects of the episodes are of equal severity and may be used to
substitute for the listed finding in a determination of equivalence”.
Explicit stressors (pregnancy, homelessness, etc.) in the absence of evidence of
significant mental impairment are not sufficient to meet the intent of the part B.
(D. for 12.05/L5) mental criteria.
7
Revision #2. Supersedes PS 03-01 “Evaluation of Disability on the Basis of Mental Disorders” dated
February 26, 2003 and January 22, 2007.
Substance abuse, in and of itself, is not considered a disabling impairment.
When the client has a dual diagnosis of substance abuse and another DSM IV
defined mental disorder, and the decision is an approval, the reviewer must
determine the materiality of the substance abuse to the disabling impairment for
MassHealth clients. (See Revised PS 98-1 dated 12/13/2005.)
Summary:
This summary of state and federal references relating to evaluation of disability
on the basis of mental disorders is provided as a tool to assist the reviewer to
make comprehensive and correct decisions. It is the reviewer’s responsibility
to read and become familiar with the full text of these regulations.
Substance abuse in and of itself is not considered a disabling impairment.
8
Revision #2. Supersedes PS 03-01 “Evaluation of Disability on the Basis of Mental Disorders” dated
February 26, 2003 and January 22, 2007.