TN 6 (03-04)

A. Policy - need for item or service

The need for an impairment-related item or service is established where a person’s disability is sufficiently severe to result in functional limitations requiring assistance in order for him or her to work. Routine drugs and routine medical services are needed when they are required to control the disabling condition, thereby enabling the person to function at work. The following requirements must be met in order to establish need for an item or service.

1. The person’s functional limitations require him or her to have assistance (items or services) in order to work; and,

2. The alleged expense meets the statutory definition of IRWE (i.e., attendant care services, durable medical equipment, prostheses, other equipment, similar items and services, or routine drugs or routine medical services necessary for the control of the disabling condition) (See DI 10520.010.); and,

3. The expense pertains to the person with a disability (not to another person); and

4. The impairment(s) which requires the person with a disability to use a particular item or service correlates with the established medical basis of disability; OR

5. The impairment(s) which requires the person with a disability to use the item or service correlates with any other medically established disability being treated by a physician or health care provider. (See DI 10520.020E.)

B. Procedure for verification and documentation of need

The FO or the claimant or recipient will record the person's allegation concerning IRWE either on the SSA-821-BK (Work Activity Report - Employee), or on the SSA-820-BK (Work Activity Report - Self-Employed Persons). The FO may also record and document issues of IRWE on a Report of Contact (SSA-5002) or the DCF REMARKS screen.

In the process of obtaining information about alleged IRWE, ask the person with a disability to explain for which impairment(s) the reported item or service is needed. For example, if the person alleges two impairments, and reports the use of two medical devices, four drugs, and a physician's treatment on a regular basis, record the person's understanding of which impairment is treated by each of the alleged items and services.

Verify that the alleged impairment agrees with either:

• the DDS established medical basis of disability (DI 26510.015G), and/or

• a disability supported by other medical records (see DI 10520.020E).

The medical records must establish the existence of an impairment that is being treated by a physician or other health care provider.

1. Comparison of IRWE, impairment and work activity

Often, it may be obvious to the FO interviewer, based on the person’s impairment(s) and description or his or her work activity, that an item or service is impairment-related and needed to enable him or her to work. When there is agreement between the IRWE, the impairment(s) and the work activity, record the justification for this conclusion on a Report of Contact (SSA-5002) or in the DCF REMARKS screen.

If a comparison of the IRWE, the impairment(s), and/or work activity does not indicate agreement, it will be necessary to verify that the item or service is actually required to control a disabling condition, or is necessary for the person to travel to and from work, or that it is essential for him or her to perform the physical and/or mental demands of his or her job.

2. Background information from person

When it is necessary to verify agreement between the IRWE and the work activity, obtain a signed and dated SSA-827 (per DI 11005.055) from the person with a disability and document the following information, as appropriate, on an SSA-5002:

• a thorough description of the physical and mental activities required in the person’s job;

• a description of the drug, item or service and for which impairment it is needed; and

• the name and address of the treating physician or health care provider.

3. Question to verifying source

When contacting the verifying source concerning the person’s need for an item or service, send an SSA-L732 with the signed and dated SSA-827 to the physician or health care provider and request the following information as appropriate and personalized to the person’s situation:

• the impairment(s) for which the person is being treated;

• is this drug, item or service necessary for the person to have the physical and/or mental capacity to perform the job duties as described, or to travel to and from work (describe job duties).

4. Issue of need unresolved

When the question regarding need is still unresolved after all efforts to verify the person’s need for an item or service through a physician or other authoritative source, consult the regional office before disallowing the IRWE. If the regional office should require any assistance in making the IRWE determination, it may contact DCRDP, OPDR, Employment Policy Team.

C. Procedure for verification and documentation of payment for item or service

1. Payment issues

There are several issues relating to payment which must be resolved:

1. For determinations of SGA, is payment made in a month the person with a disability is working? (See DI 10520.030 for rules regarding payments made on durable items before the person started working, or payments made on items or services after the person stopped working.)

2. For determinations of SSI countable earned income, is payment made in a month earned income is received? (See DI 10520.030.)

3. Does the payment pertain to an item that is used, or a service that is received, in a month in which the person with a disability is working?

4. Is the payment within reasonable limits? See DI 10520.025D.

5. Is the payment made by the person with a disability?

2. Obtaining proof of payment

The person with a disability must provide proof that he or she paid for the item or service. A verifying statement signed by the person (SSA-795) and copies of cancelled check(s), or paid receipt(s), etc., would be adequate to prove payment. The SSA-795 should include a statement that no reimbursement was or will be received for the IRWE and that no agency or other source is underwriting the expense for the person.

1. Where the person with a disability is unable to provide proof of payment, contact the prescribing source (if also the supplier) or the supplier of the item or service to verify payment.

2. Diary for future review, either in the month the IRWE are expected to end, or 12 months from the date of the determination, cases in which IRWE are material to a determination of either SGA or SSI countable earned income (See DI 10520.065.). At the time of review, the beneficiary must provide proof that he or she did, in fact, pay the IRWE on the basis of which the determination of SGA or SSI countable earned income was made. The FO should advise the claimant or beneficiary that his or her records will be reviewed, and he or she should, therefore, retain all appropriate receipts and proofs of payment in order to be able to demonstrate that payments were made during the diaried period.

3. Services by a family member

Whenever services (attendant care, transportation) are involved, document the file if the provider is a family member. The following documentation must also be included on an SSA-795 signed by the person with a disability and the family member:

1. A statement of family member’s duties and periods of time when performed;

2. Certification that services have been rendered and that payment in cash (including checks or other forms of money, but not payment in-kind) is being received from the person with a disability;

3. Evidence that payment was made (e.g., cancelled checks);

4. Information which establishes prior ongoing employment of the family member before the issue of attendant care became relevant to the person with a disability;

5. A statement that establishes how the family member suffers an economic loss by serving as attendant or driver (e.g., identify the job that the attendant relinquished, or document the reduction of hours in other remunerative work, and record the date that work stopped or hours were reduced).

Where appropriate, ascertain whether or not these payments have been reported under the Federal Insurance Contributions Act (FICA). Such reporting helps establish the credibility of attendant care payments and protects the interest of the person rendering such services.

4. Reimbursement of expense

Deduction of IRWE is not allowable to the extent that the person with a disability has been, could be, or will be, reimbursed for such expenses by any source (such as through a private insurance plan, Medicare or Medicaid eligibility, or other plan or program).

1. Any portion of IRWE the person with a disability pays that is not reimbursed or not reimbursable is allowable as a deduction. If, for example, a person pays $80 for crutches and receives no reimbursement, the full $80 is allowed as a deduction. But if an agency, plan, or program reimburses him $64 of the $80 purchase price, his IRWE deduction is only $16. (If, pursuant to the reasonable limits provision, it is found that the standard cost of these crutches is $70 rather than $80, only $6 ($70 minus $64) is deductible.)

2. If the person with a disability reports there is no possibility of reimbursement from a private insurance plan, obtain a signed statement to that effect.

3. Verification of Medicare or Medicaid eligibility should be obtained from appropriate queries and records.

4. When the person with a disability alleges that Medicare did not pay 80 percent of the reasonable charges, or that the charge for the item or service satisfied part or all of the annual deductible, the person must provide proof of these allegations.

D. Procedure for verification and documentation that payment is within reasonable Limits

Deduct the actual amount paid for IRWE unless the amount is unreasonable. The amount is within reasonable limits if it is no more than the prevailing charge for the same item or service. Prevailing charges are those which fall within the range of charges that are most frequently and widely used in a community for a particular item or service. The top of this range establishes the standard or normal cost that can be accepted as within reasonable limits for a given item or service.

When there is a question about whether the amount a person with a disability paid (or is paying) for a service or item is within reasonable limits, undertake the following development to compare the paid amount with the prevailing charge, and record the findings and conclusion on an SSA-5002.

1. Where FO experience reflects that the amount paid for any service or item is unreasonable, or the cost of the service or item on its face appears unreasonable, contact other sources in the community who provide the same item or service to ascertain the standard or normal costs for such an item or service. Community in this context means the area in which the person with a disability resides and normally conducts commercial transactions.

2. If there is no source of the necessary item or service in the community or perhaps only one source is available, the term community would include the commercial locale in closest proximity to the person’s area of residence where such item or service would be available.

3. In the event that development with community sources is unproductive in providing cost information, the person with a disability (or the FO on his or her behalf) may contact the local vocational rehabilitation (VR) agency to determine if they have cost information pertaining to the item or service in question.

4. Where these inquiries provide information establishing that the cost he or she paid is unreasonable, i.e., outside the range of prevailing charges, then use the standard or normal cost that is established from the sources contacted (not to exceed the actual amount paid) as the deductible amount. Document the file with the comparative cost data obtained.

If none of the sources contacted is productive, so that the issue of reasonable limits for a particular item or service is unresolved, consult the regional office. If the regional office should require any assistance, it may contact DCRDP, OPDR, Employment Policy Team.