DI 12027.010 Processing Statutory Benefit Continuation (SBC)
The individual affected will receive a medical cessation notice (or notice of a medical adverse reopening/revision determination) about the adverse action. The notice will provide information about contacting the field office (FO) to request appeal and the option of SBC. The individual may choose to elect or decline SBC.
A. Policy - Who May Sign the SBC Election Form
The beneficiary eligible for SBC must sign the appropriate election form, unless he/she is incompetent or a minor child.
Once an appeal of the medical cessation (or medical adverse reopening/revision determination) is filed, the beneficiary’s representative payee may sign the appropriate election form because the beneficiary and payee will both be responsible for repayment of any overpayment.
An authorized representative (attorney or non-attorney) may not sign the election form on the beneficiary’s behalf because an authorized representative will not be responsible for repayment of any overpayment.
If an authorized representative signs an election form and it is filed timely, it will serve as a protective writing for SBC if a properly signed election statement is later submitted. The beneficiary (or representative payee, where appropriate) must sign an appropriate election form for the beneficiary to receive SBC.
B. Procedure – When Individual Contacts FO Regarding SBC
When an individual receives his/her medical cessation notice (or notice of a medical adverse reopening/revision) informing him/her of the adverse action, he/she may contact the FO by telephone, mail or office visit.
In each of these methods of contact, the FO will:
1. Explain SBC Requirements to the Individual
2. Explain the Appeal Information to the Individual for His or Her Appropriate Appeal Level
Reconsideration — Medical Cessations and Favorable Initial and Reconsidered Determinations Revised Due to Medical Reasons - Title II and Title XVI, DI 12026.001 — DI 12026.025
Request for Administrative Law Judge (ALJ) Hearing, DI 12010.001
NOTE: The FO processes requests for ALJ hearings of continuing disability issues exactly as they process requests for ALJ hearings on initial claims.
Requesting Appeals Council (AC) Review, DI 12020.001.
3. Explain the Time Limits for Both SBC and Appeals to the Individual
See Evaluating the Time Limit for Electing Statutory Benefit Continuation (SBC), DI 12027.008
See Time Limit for Filing Appeal, GN 03101.010
4. Provide SBC Election Statement (SSA-795) to the Individual
A separate election statement (SSA-795) is required at each level of appeal.
The election statement must be specific to the claim type:
Title II Benefit Continuation Election Statement
Auxiliary Benefit Continuation Election Statement
Title XVI and Concurrent Title II/Title XVI - Benefit Continuation Election Statement
Extended Period of Eligibility (EPE) Continuation Election Statement
IMPORTANT: In concurrent cases, complete Exhibits 1 and 3, DI 12095.171.
See SSA-795 Election Statement - Exhibits, DI 12095.171 for the exhibits of the specific election statements. In concurrent cases, complete Exhibits 1 and 3.
NOTE: Explain to the individual that the election statement is required whether he/she elects or declines SBC.
5. Provide Appeal Forms to the Individual
Appealing the medical cessation (or medical adverse reopening/revision determination) is required for the individual to have the option of SBC. See DI 12027.001A.
The appeal forms must be appropriate to the individual’s level of appeal. See DI 12027.010B.2.
6. Assist the Individual in Completing Any Forms if Assistance is Needed or Requested by the Individual
If the individual needs or requests help in completing any forms, assist them to do so.
7. Document the Contact
a. Contact made by telephone or mail - SBC and appeal forms mailed to individual
Use the Modernized Supplemental Security Income Claims Systems (MSSICS) and/or Modernized Claims System (MCS) development worksheets to set-up control dates.
Set up tickle dates for receipt of the SBC election statement and appeal forms 15 days from the medical cessation notice date.
If the case is not active in either MSSICS or MCS, use the Modernized Development Worksheet (MDW).
Setting up control and tickle dates documents the individual’s contact with the Social Security Administration (SSA) for protective filing purposes.
b. Contact made by FO visit:
Set up the necessary control dates to document the contact when the individual does not complete the SBC election statement and/or appeal forms at this FO visit. Follow DI 12027.010B.7.a.
Follow DI 12027.010B.8. through DI 12027.010B.10., when the individual provides the SBC and appeal forms to the FO.
See DI 12027.010C. for SBC systems inputs.
8. Individual Declines SBC
Place election statement showing that the individual declined SBC in the individual’s official folder. See DI 12027.008B.10.
Provide a copy of the signed election statement (SSA-795) to the individual.
9. Individual Elects SBC
Place election statement indicating individual elected SBC in the individual’s official folder. (See DI 12027.008B.10.)
Provide the individual a copy of the signed election statement (SSA-795).
Follow the systems instructions in DI 12027.010C.
10. Folder Documentation
Fax the signed election statement (SSA-795) into section E of the electronic folder (EF), if the official folder is electronic. Verify the document is in the EF then shred the original per Paper Retention Timeframes.
Place the signed election statement (SSA-795) in the blue section of the modular disability folder (MDF), if the official folder is paper.
C. Procedure - Systems Input for SBC
Initiation and/or termination of SBC payments require automated or manual systematic actions. The following references contain detailed procedures for the appropriate systems action.
1. Use the following references for Title II systems input (including SBC in Extended Period of Eligibility (EPE) cases):
Processing Center instructions are found in SM 00614.000,
FO instructions for POS inputs are in MSOM T2PE 002.003 (POS), MSOM T2PE 003.024 (PEC1), and T2PE 003.025 (PEC2)
For cases requiring critical payments see SM 00635.000 (CPS).
2. Use the following references for Title XVI systems input:
MSOM BUSSR 002.010, MSOM BUSSR 002.020, and MSOM MSSICS 020.015; and
SM 01305.580, SM 01305.585 and SM 01601.685.
3. Use the following references for Medicare (process continuation through Manual Adjustment Credit and Award Process (MADCAP):
Disability Cessation Process, SM 00614.001
Overview of MACADE/MADCAP, SM 00801.001
Accessing MACADE/MADCAP SM 00801.010
Disability Appeal Processing -- P.L. 97-455, SM 00850.540
Medicare Continuation During Appeal of Title II Disability Cessation, HI 00801.161
Cessation of Disability, HI 00820.100