DI 12027.050 Processing Statutory Benefit Continuation (SBC) in Non-Payment for Non-Medical Reasons
A. Policy – Benefit in Suspense at Time of Medical Cessation Appeal – Title XVI
A Title XVI beneficiary in non-payment for a non-medical reason when disability is ceased may elect SBC during cessation appeal only at the time the non-medical requirement is met (and only if the appeal is still pending).
The cessation determination/decision notice will contain modified SBC language explaining when an SBC election may be made.
B. Procedure – Benefit in Suspense at Time of Medical Cessation Appeal – Title XVI
1. Payments Remain in Suspense During Appeal
An SBC election/waiver is not obtained if the non-medical requirement is not met when the cessation appeal is requested.
The field office (FO) will:
Inform the claimant that he/she can elect or decline SBC if he/she meets the non-medical requirements later and the appeal is still pending. See DI 12027.010 for the procedure on requesting SBC.
Process the appeal and update the Supplemental Security Income Record (SSR) to record the cessation appeal in the routine manner, leaving payment in suspense.
2. Title XVI Payments Reinstated During Appeal
When a Title XVI claimant requests SBC because the non-medical requirement is currently met and payments will be reinstated during appeal, the FO will:
Verify that the cessation appeal is still pending.
Redetermine Title XVI eligibility factors in the routine manner.
Give the claimant an opportunity to elect or decline Title XVI SBC. Follow SBC provisions and processing instructions in DI 12027.001 through DI 12027.010.
Reinstate benefits at the Protected Payment Level (PPL) effective prior to the non-disability suspension if claimant elects SBC.
3. Title XVI SBC Payments Being Paid and Claimant Becomes Ineligible
Send the claimant an SSI Notice of Planned Action (SSA-L8155-U2) which includes Goldberg/Kelly (GK) appeal rights and payment continuation on the adverse action to suspend SBC for a non-medical factor. See SI 02301.300 for GK protection information.
4. Title XVI Non-payment for a Non-medical Reason Issues
See SI 00800.000 for cases involving excess income.
See SI 01100.000 for cases over the resource limit.
See SI 00520.000 regarding institutionalization (including prisoner suspension).
C. Policy – Suspension for Substantial Gainful Activity (SGA) – Title II
SBC must be suspended for months of SGA after Trial Work Period (TWP) and may be reinstated for months of non-SGA.
Suspension of SBC is not an initial determination subject to appeal.
Due process notice must be sent before suspension.
D. Procedure - Suspension of SGA – Title II
SGA and TWP determinations made during SBC are eWork exclusions. Use the procedures outlined in DI 13010.026 to document work determinations.
1. Development Shows SGA
The FO will:
Verify reported work activity and earnings.
Determine if beneficiary is entitled to a TWP (See DI 13010.035).
Query the DCF and eWork information to determine if there were prior months of trial work.
2. SGA and TWP Exhausted
If beneficiary is engaging in SGA and TWP is exhausted, the FO will:
Not prepare an SSA-833-U3 SGA determination while the medical cessation appeal is pending.
Prepare Work Activity Report - Employee (SSA-821-F4) if beneficiary has an employer. See Documenting Employment Cases Using the SSA-821-BK (Work Activity Report-Employee) and the SSA-823 (Report of SGA Determination-For SSA Use Only), DI 10505.035.
Prepare Work Activity Report - Self-Employment (SSA-820-F4) if beneficiary is self-employed. See Documenting Self-Employment Cases Using the SSA-820-BK (Work Activity Report-Self-Employment) and the SSA-823 (Report of SGA Determination- For SSA Use Only), DI 10510.025.
Send advance (due process) notice of suspension.
Notify appropriate Processing Center (PC) to suspend SBC effective the current SGA month (do not make retroactive adjustment for SGA) after 15 days. The FO will provide the PC the following information:
SSA field office (FO) information: FO Code, Sender's Name, Sender's Telephone Number
Title: Title II, Suspension of Benefit Continuation Payments - SGA
Claim Account Number (CAN): The wage earner's social security number.
Beneficiary Identification Code (BIC) - (up to three alphanumeric positions) that was assigned for Title II purposes;
Name: Surname followed by the first three letters of the individual's given name
Suspension months: Specify the months for which payments should be suspended and whether the suspension is to continue
If an ALJ case, forward the original Form SSA-821-F4/820-F4 to the HO.
Follow DI 12027.050D.3. if beneficiary protests proposed SGA suspension.
3. Beneficiary Responds That Work Is Not SGA
If beneficiary states work is not SGA:
Review any new evidence and/or develop to resolve conflict.
Process suspension or continue payment accordingly.
Send beneficiary notice on an SSA-L951-U2 explaining outcome, excluding appeal rights.
4. SGA - Eligible For TWP
If work is SGA and the beneficiary is eligible for TWP:
Hold SSA-821-F4 (SSA-820-F4) and tickle for end of TWP.
Provide the original form to the HO for association with the official folder.
Update and verify work and earnings information if cessation appeal is still pending at the end of the TWP.
Follow DI 12027.050D.2. if both SGA and TWP exhausted.
5. Reinstatement - Work Below SGA
Follow Reinstate or deny benefits during the EPE, DI 13010.215B, when reinstatement is for months that are below SGA, provided the medical cessation appeal is still pending.
E. Policy - Suspended Title II Prisoner Beneficiary - Medical Cessation/Adverse Reopening/Revision Determination
Disability Insurance Benefits, Childhood Disability Beneficiary, and Disabled Widow(er) Benefits (DIB, CDB and DWB) beneficiaries generally will be in suspense status at the time of the medical cessation/adverse reopening/revision determination.
1. Ceased Prisoner Beneficiary
A ceased prisoner beneficiary:
Is not eligible for SBC if he/she appeals the medical cessation or adverse reopening/revision determination.
May become eligible for SBC upon release from prison, if the medical appeal is still pending at the time.
2. Eligible Auxiliaries
Eligible auxiliaries who are receiving benefits at the time of the cessation/adverse reopening/revision determination are eligible for SBC during appeal.
3. Modified Cessation Reopening/Revision Notice
A modified cessation reopening/revision notice is required to:
Explain to the ceased prisoner beneficiary:
Explain to eligible auxiliaries the SBC provisions.
F. Procedure - Suspended Title II Prisoner Beneficiary - Medical Cessation/Adverse Reopening/Revision Determination
1. Ceased Prisoner Appeal
For ceased prisoner appeals, the FO will:
Process (medical) appeal in the routine manner.
Obtain SBC election form for any auxiliaries.
Notify the appropriate PC of SBC data.
2. Reinstatement Requested Upon Prison Release
When reinstatement is requested upon prison release, the FO will:
that appeal is pending on medical cessation or medical adverse reopening/revision determination.
claimant's release date with appropriate authorities. See Title II Reinstatement Policies for Prisoners, GN 02607.840B.
that all other eligibility factors continue to be met. See Factors Affecting Eligibility - Policy, GN 02602.005
Obtain signed SBC election statement, SSA-795. Follow SBC provision instructions in DI 12027.001 through DI 12027.010.
Remind claimants of reporting responsibilities while receiving SBC benefits.
Reinstate benefits effective the first full month of non-confinement. (See Title II Reinstatement Policies for Prisoners, GN 02607.840.)
Do not withhold any of these benefits for possible attorney fees.
Notify the appropriate PC to request benefit reinstatement. The FO will provide the PC the following information:
SSA FO (City, State); DO Code, Sender's Name, Sender's Telephone Number
Title: Prior Prisoner Case Reinstatement Now Applicable
CAN: The Wage Earner's SSN
BIC: The Beneficiary Identification Code for the suspended beneficiary
Name: The suspended beneficiary's surname followed by the first name and initial
Event Date: (MM/YY) Effective month benefits are to be resumed (first full month of non-confinement)
Remarks: Reason for reinstatement (e.g., parole, completion of sentence, commutation of sentence, conviction overturned, etc.) - Title II, SBC Pending Medical Cessation/Reopening Appeal
The FO will:
Verify that the reinstatement has been processed in 45 days.
Contact the PC to request reinstatement if the query shows that reinstatement has not been processed.
NOTE: See Title XVI Prisoner Provision, GN 02607.050.