The last month of elected SBC payment is through the earlier of:

1. 1. 

   The month before the month of the ALJ decision, or the month before the month of a new ALJ decision (or final action by the AC on an ALJ's recommended decision) if the AC remands the case to an ALJ for further action; or

2. 2. 

   The month before the month in which no timely request for reconsideration or an ALJ hearing is pending.

   EXAMPLE:

   • •

     Remy’s cessation month is July 2006.

     Her termination month would be October 2006.

   • •

     Remy filed a timely request for an appeal and SBC in July 2006.

     SBC begins in October 2006.

   • •

     An unfavorable reconsideration determination was made in October 2006.

     NOTE: If Remy does not appeal to the ALJ, December is the last month of SBC payment. (See DI 12027.020B.2.)

     The SBC months of October through December are overpayments.

   • •

     However, Remy does file a timely request for both an ALJ hearing and SBC in November 2006, so SBC will continue.

   • •

     If the ALJ decision, made for example in June 2007, is unfavorable, the last month of SBC payment will be May 2007. (See DI 12027.020B.1.)

   Any SBC payment(s) paid to Remy October 2006 and after are considered overpayments.

When an appeal determination/decision of a medical cessation (or adverse medical reopening/revision) is made at the reconsideration or ALJ hearing level (or the ALJ dismisses the request for an ALJ hearing), the affected individual will receive a notice from Disability Determination Services (DDS) or the Hearing Office (HO) about the appeal determination, decision or dismissal.

If SBC payments were being received during his/her appeal process:

• •

  When the appeal determination/decision by DDS or HO is favorable, the FO will terminate SBC payments and reinstate regular payments.

• •

  When the determination/decision is unfavorable (or there is a dismissal of the request for an ALJ hearing), then the notice will include appeals language and SBC payments must be terminated.

The FO must terminate SBC in the appropriate month and in a timely manner. Any months of SBC will be an overpayment, subject to all the usual waiver rules.

• •

  See The Last Month of SBC Payment, DI 12027.020B.

• •

  See Waiver Provisions for Title II and Title XVI Overpayments, GN 02250.000.

• •

  SBC payments are not overpayments until the medical cessation decision is final. The medical cessation decision becomes final when the individual does not request further review within the appeal period (or has good cause for a untimely filed appeal) or has exhausted all levels of appeal. See GN 02201.009C

• •

  By law, the individual must appeal the medical cessation in good faith to be offered waiver consideration. If the individual does not appeal in good faith, do not offer waiver consideration. The FO must consider any physical, mental, educational, or linguistic limitations in determining good faith.

• •

  For instructions on processing requests for waiver of recovery of overpayments in disability cessation appeal cases with SBC involvement see:

  • –

    Waiver Provisions for Disability Cessation Cases, SI 02260.007

  • –

    Payment Continuation – Waiver Title II, XVI, GN 02250.036

• •

  If the claimant is receiving SBC and WC payments at the same time, then the current rules regarding WC offset apply.

• •

  When electing SBC, if WC offset applies to benefits at the time of cessation, continue applying WC offset and make adjustments as if the individual were receiving regular disability (DIB) payments.

• •

  If WC is first received during the SBC period, offset will begin at that time as if the individual were receiving regular disability (DIB) payments.

See Offset Provisions, DI 52101.001 regarding workers' compensation offset.