TN 1 (09-17)

DI 11080.005 Processing Consolidated Omnibus Budget Reconciliation Act (COBRA) Disability Cases

A. Processing requirements

Claimants do not have to meet the non-disability requirements for Title II (e.g., insured status or an onset date more than 5 months before full retirement age (FRA)) or Title XVI (e.g., income or resources) to qualify for the additional 11 months of health care benefits under COBRA. To ensure that the claimant receives a prompt determination, handle all COBRA claims expeditiously.

If the disability determination services (DDS) or the Philadelphia disability processing unit (PH-DPU) finds the employee, spouse, or dependent child disabled under the Social Security Act within 60 days of the COBRA qualifying event, he or she may receive an additional 11 months of health care benefits under COBRA. The Social Security Administration (SSA) is only responsible for making disability decisions for the extension of COBRA coverage (the additional 11 months). See DI 11080.001 for additional details about the qualifying events and SSA’s responsibility.

  1. For Title II and concurrent cases, the DDS determines an onset as in any Title II disability claim. We use the onset date, established by the DDS, to determine eligibility for COBRA.

  2. In Title XVI-only cases, the DDS usually uses the date of filing or protective date of filing as the onset. In COBRA cases, however, the DDS must establish an actual medical onset date. If this is not possible, the DDS attempts to establish disability within the first 60 days of COBRA coverage.

To extend health care coverage under COBRA based on disability, the individual must:

  • File for disability benefits (Title II, Title XVI, or concurrent) with COBRA extension, or

  • File for COBRA extension only.

Claims in which the individual files for disability benefits and requests a COBRA determination are the jurisdiction of the DDS. COBRA only determinations are the jurisdiction of the PH-DPU. See DI 11080.005E in this section.

IMPORTANT: While the SSA does not require proof of COBRA entitlement (such as dates of entitlement to COBRA, relationship, date decision required), it is in the claimant’s best interest to provide verification in order to make a timely decision.

B. Individual meets the non-disability requirements for Title II disability benefits

When an individual applies for COBRA extension, we must still process the case in the Modernized Claims System (MCS). To ensure proper handling of COBRA cases use the following procedures:

  1. Take a disability claim in MCS:

    • Add “COBRA” as an ISSUE on the DW01 screen to help identify COBRA cases easily;

    • Add the date of the application to the REQ field;

    • Establish a 30 day tickle for the first follow up with the DDS;

    • Receipt in the COBRA issue with the date the DDS returns a medical determination; and

    • Ensure the DW01 has the “DDSDEC” issue to control for case return from the DDS.

  2. Establish and complete the Electronic Disability Collect System (EDCS) screens for the disability claim (disability insurance benefits (DIB), disabled widow(er)’s benefits (DWB), and childhood disability benefits (CDB) claims), and complete the following additional items:

    • Complete an SSA-5002 (Report of Contact). Include the statement: “Individual must meet the medical requirements for disability during the period MM/DD/YYYY through MM/DD/YYYY to qualify for extension of COBRA continuation coverage.” Include the primary beneficiaries’ name and social security number (SSN). (Enter the dates of the first 60 days of COBRA coverage);

    • Annotate “COBRA case” and the date that the employee must notify the health plan administrator on the SSA-5002 (end of initial 18 months of COBRA coverage) and in the remarks section of the SSA-3367 (Disability Report—Field Office);

    • Add the “Special Handling” flag and annotate “COBRA Case” in the description field to ensure that the DDS can easily identify the COBRA case and make a timely determination; and

    • Transfer the case to the DDS.

  3. Advise the individual that the DDS will make a medical determination and if favorable, he or she may use the award notice to notify the plan administrator.

NOTE: For non-electronic cases, follow routing instructions in DI 11080.005D.2. in this section.

C. Individual meets the non-disability requirements for Title XVI disability benefits

When an individual applies for COBRA extension, we must still process the case in the Modernized Supplemental Security Income Claims System (MSSICS). To ensure proper handling of COBRA cases use the following procedures:

  1. Take a full Supplemental Security Income (SSI) disability claim in the MSSICS:

    • Add “COBRA” as an ISSUE on the DW01 screen to help identify COBRA cases easily;

    • Add the date of the application to the REQ field;

    • Tickle for the first follow up with the DDS for 30 days;

    • Receipt in the issue with the date the DDS returns the medical determination; and

    • Ensure the ADIB screen is complete and the DW01 has the “DDSDEC” issue to control for case return from the DDS.

  2. Complete EDCS screens for the SSI claim:

    • Complete an SSA-5002 (Report of Contact). Include the statement: “Individual must meet the medical requirements for disability during the period MM/DD/YYYY through MM/DD/YYYY to qualify for extension of COBRA continuation coverage.” Include the primary beneficiary name and social. (Enter the dates of the first 60 days of COBRA coverage);

    • Annotate “COBRA case” and the date that the employee must notify the health plan administrator on the SSA-5002 (end of initial 18 months of COBRA coverage) and in the remarks section of the SSA-3367 (Disability Report—Field Office);

    • Add the “Special Handling” flag, and annotate “COBRA Case” in the description field to ensure that the DDS can easily identify the COBRA case and make a timely determination; and

    • Transfer the case to the DDS.

    NOTE: Claims in which the individual requests to file for disability benefits and requests a COBRA determination are the jurisdiction of the DDS. (COBRA only determinations are the jurisdiction of the PH-DPU. See DI 11080.005E in this section).

  3. Upon receipt of a Title XVI allowance, prepare a separate letter for the individual advising him or her of the date of onset and that he or she meets the disability criteria under Title XVI of the Social Security Act within the first 60 days of COBRA coverage. This should be on the SSA-5002.

IMPORTANT: The systems generated Title XVI allowance notice will not have the actual established onset date (EOD) determined by the DDS. It is best for the claims specialist (CSR) to use the notice general notice template housed in the Document Processing System (DPS) to manually generate a notice and input the correct EOD. Advise the individual to use the award notice to notify the plan administrator. For non-electronic cases, follow routing instructions in DI 11080.005D.2. in this section.

D. Individual meets the non-disability requirements for concurrent Title II and Title XVI

When an individual applies for COBRA extension, we must still process the case in MCS and MSSICS. To ensure proper handling of COBRA cases use the following procedures:

  1. Take a disability claim in MCS and in MSSICS:

    • Add “COBRA” as an ISSUE on the DW01 screens to help identify COBRA cases easily;

    • Add the date of the application to the REQ field;

    • Establish a 30 day tickle for the first follow up with the DDS;

    • Receipt in the COBRA issue with the date the DDS returns a medical determination;

    • In MCS, ensure the DW01 has the issue “DDSDEC” to control for case return from DDS; and

    • In MSSICS, ensure the ADIB screen is complete, and the DW01 has the issue “DDSDEC”.

  2. Establish and complete the EDCS screens for concurrent Title II (DIB, DWB or CDB) and Title XVI claim:

    • Complete an SSA-5002 (Report of Contact). Include the statement: “Individual must be found to meet the medical requirements for disability during the period MM/DD/YYYY through MM/DD/YYYY” to qualify for extension of COBRA continuation coverage. Include the primary beneficiary’s name and social security number. (Enter the dates of the first 60 days of COBRA coverage);

    • Annotate “COBRA case” and the date that the employee must notify the health plan administrator on the SSA-5002 (end of initial 18 months of COBRA coverage) and in the remarks section of the SSA-3367 (Disability Report—Field Office);

    • Add the “Special Handling” flag, and annotate “COBRA Case” in the description field, to ensure that the DDS can easily identify the COBRA case and make a timely determination; and

    • Transfer the case to the DDS

  3. Advise the individual that the DDS will make a medical determination and if favorable, he or she may use the award notice to notify the plan administrator.

NOTE: For non-electronic cases, follow routing instructions in DI 11080.005D.2 in this section.

E. Individual does NOT wish to file for disability benefits and does Not meet the non-disability requirements for Title II nor Title XVI

Do not take a Title II application unless individual wants to file. If the individual does want to file a Title II application, process an abbreviated application (ABAP) in MCS. Otherwise, ensure the individual received a Title II close out notice. Also, close out Title XVI by issuing an SSI informal denial notice (SSA-L-991) or by securing and processing and an ABAP in MSSICS.

  1. Forward COBRA determinations requests to the PH-DPU, and take the following actions:

    • Complete a paper SSA-3368 (Disability Report – Adult) or SSA-3820 (Disability Report – Child) as needed;

    • Document medical sources from the alleged onset date;

    • Obtain as much medical evidence as possible from the applicant. If the claimant can obtain medical evidence not in his or her possession, advise him or her to bring it into the office immediately, but do not delay mailing the application and all related documents in the claims folder to PH-DPU more than two days;

    • Obtain an SSA-827 (Authorization to Disclose Information to the Social Security Administration);

    • Complete an SSA-5002 (Report of Contact). Include the statement: “Individual must be found to meet the medical requirements for disability during the period MM/DD/YYYY through MM/DD/YYYY to qualify for extension of COBRA continuation coverage.” (Enter the dates of the first 60 days of COBRA coverage);

    • Annotate “COBRA case” and the date that the employee must notify the health plan administrator on the SSA-5002 (end of initial 18 months of COBRA coverage) and in the remarks section of the SSA-3367 (Disability Report—Field Office);

    • Assemble the material in a yellow modular folder; and

    • Add the “Special Handling” flag, and annotate “COBRA Case” in the description field to ensure that the PH-DPU can easily identify the COBRA case and make a timely determination.

  2. Do NOT prepare a disability determination and transmittal (SSA-831). Send COBRA only cases via FedEx (express or overnight mail) annotate routing cover with “COBRA Case.” Mail to:

    SSA, Philadelphia Disability Processing Unit
    6401 Security Blvd.
    Cubicle 3608, 3rd Floor Annex Building
    Baltimore, MD 21235
  3. Fax subsequent information provided by the claimant to the PH-DPU. The information should indicate that it should be associated with the pending COBRA case. Fax the information to 1–800–582–1108 for expeditious handling.

  4. The PH-DPU prepares and releases the appropriate notice for these cases and returns the completed case to the field office (FO), along with a special determination (SSA-553) of disability and a copy of the notice.

    • Use the Manual Development Worksheet (MDW) to control and document these cases. Retain the M