BASIC (10-06)

DI 12027.065 Appeals Council (AC) Remand Medical Cessation Cases – Statutory Benefit Continuation (SBC) - Title XVI and Concurrent Title II/Title XVI

A. Policy – AC Remand Medical Cessation Cases – SBC – Title XVI and Concurrent Title II/Title XVI

The policy for Title XVI and concurrent Title II/Title XVI, as it pertains to SBC, is the same as for the Title II AC remand policy for SBC. See DI 12027.060A.

B. Process – AC Remand Medical Cessation Cases – SBC – Title XVI and Concurrent Title II/Title XVI

In Title XVI (including concurrent Title II/Title XVI)) medical cessation appeal cases remanded to an Administrative Law Judge (ALJ), the AC will send to the servicing field office (FO) a:

  • copy of the remand order,

  • payment status request (DI 12095.172, Exhibit 1), and

  • Form HA-505 (Transmitted by Office of Disability and Adjudication Review/Hearing Office (ODAR/HO) annotated:

    “Possible Title XVI - SBC Case. Please review queries and take the actions indicated on the attached SSI payment status request immediately.”

The AC will notify the servicing HO, identifying it as a possible SBC case.

ALERT:  Process the Title II portion of a concurrent remand under the Title II procedure per DI 12027.060.

C. Procedure - AC Remand Medical Cessation Cases – SBC – Title XVI and Concurrent Title II/Title XVI

1. Prior to Initiating SBC Payment

The FO will:

  1. Telephone the HO to obtain the recipient's payment status.

  2. Fax the payment status request (DI 12095.172, Exhibit 1) to the HO.

ALERT:  The HO will send the appropriate SBC notice to the recipient (and a copy to the representative, if any). This notice informs recipient about his/her right to reinstatement or waiver of SBC benefits and possible overpayment.

2. SBC Elected Before Prior ALJ Decision – Recipient Not in Pay

If SBC was elected before the prior ALJ decision but benefits are not being paid, the FO will:

  1. Contact recipient to:

    • Complete a redetermination (RZ) for Title XVI. (See SI 02305.001.)

    • Verify recipient's SBC election.

  2. Obtain development needed to resume SBC, if SBC not waived.

  3. Process in accordance with the following chart:

If the recipient elects reinstatement of SBC and alleges:

Then:

No work, and according to the allegation, non-disability factors will not lower the protected payment level (PPL) amount

  • Reinstate current payment of SBC immediately.

  • Notify the recipient using an SSA-L8165-U2.

  • Process RZ for non-disability Title XVI factors.

  • Issue retroactive payment beginning with the month terminated by the ALJ's decision.

A non-disability change (e.g., income or living arrangement change) permitting payment at less than the PPL

(See SI 02301.325)

  • Reinstate current payment of benefits immediately at the PPL.

  • Notify the recipient using an SSA-L8165-U2.

  • Process RZ for non-disability Title XVI factors.

  • Notify the recipient of the reduced payment amount and his/her right to appeal using an SSA-L8155-U2.

  • Reduce the PPL.

  • Reinstate payments at the reduced PPL retroactive to the month terminated by the ALJ's decision.

Non-disability changes that do not permit payment (e.g., excess resources)

  • Reinstate payment immediately.

  • Notify the recipient using an SSA-L8165-U2.

  • Process RZ for non-disability Title XVI factors.

  • Issue an SSA-L8155-U2.

  • Process an adverse action.

  • Do not reinstate retroactive payments

ALERT:  Process any subsequent changes in non-disability factors as a subsequent event during a period of SBC (see SSI Posteligibility Changes, SI 02301.001). This includes changes in non-disability factors resulting from verification, the SSI redetermination process, or other recipient contacts subsequent to reinstatement.

3. SBC Elected Before ALJ Decision - In Pay Status

If SBC elected before ALJ decision and benefits are being paid, the FO will:

  1. Review the information to verify that payment status and benefits are correct.

  2. Adjust Title XVI payments as necessary.

4. Recipient Initiates Contact

If the recipient contacts the FO before the FO receives the HO notice regarding SBC and states that his/her case was remanded, the FO will:

  1. Call the last servicing HO office that had the claim to verify that a remand order was issued and obtain the date of the order.

  2. Obtain the recipient's signature that he/she elects or declines SBC on an SSA-795 (if the remanded case is still pending without a final ALJ decision or dismissal order). See DI 12027.010B.4.

  3. Provide the SSA-795 SBC election statement to the HO for the official folder.

  4. Develop good cause for failure to file timely (if necessary). See DI 12027.008B. Develop good cause per GN 03101.020 if:

    • The recipient alleges good cause for failure to request SBC when the original adverse notice or reconsideration notice was issued, and

    • No good cause determination on the issue had been made previously.

  5. Redetermine Title XVI eligibility and process SBC per DI 12027.010.

  6. Issue an SSA-L8165-U2 notice.

  7. Contact the servicing HO to determine whether the AC has issued a remand order and current status of the claim. The HO will send written confirmation of the status (see DI 12095.172, Exhibit 2). The HO will not send an SBC notice to the recipient.

5. Recipient Did Not Elect SBC at Prior ALJ Level

The FO will:

  1. Give the recipient 10 days from the receipt of the HO notice to request SBC. Consider a request timely if it is made within 10 days (allow for 10 days plus 5 days for mailing) from date of the HO notice regarding SBC.

  2. Process in accordance with the following chart:

If the recipient:

Then:

Does not contact the FO

Take no action on SBC.

Contacts the FO more than 15 days after the date of the HO reinstatement notice.

Develop good cause per GN 03101.020.

Contacts the FO to request SBC benefits

  • Query the Supplemental Security Income Record (SSR).

  • Locate a copy of the reinstatement notice from the official folder.

  • Check the Case Processing and Management System (CPMS) for the HO appeal status (as necessary).

  • Have the recipient sign an election statement (SSA-795).

  • Send the signed election statement (SSA-795) by fax into section E of the electronic folder (EF), if the official folder is electronic. Verify the document is in the EF, and shred the original per DI 81020.055.

  • Place the signed election statement (SSA-795) in the blue section of the modular disability folder (MDF), if the official folder is paper.

  • Process RZ for non-disability Title XVI factors.

  • Reinstate payment at the PPL effective with the month of the AC remand order if the non-disability factors permit payment (see SI 02301.325).

  • Do not reinstate payments if non-disability factors do not permit payment or if the recipient is rendering SGA (prior to 7/87), and process an adverse action using an SSA-L8166-U2 or expedite SGA development.

6. SBC Reinstatement Date

Reinstate SBC upon remand in accordance with the following chart:

If the recipient:

Then:

Received SBC until the ALJ decision

Reinstate retroactive to the month continued payments previously terminated as a result of the prior ALJ decision.

Received a medical cessation and was eligible for SBC

but did not request SBC timely and good cause was not found for failure to file timely,

OR for any reason did not receive SBC before the prior ALJ decision

Reinstate the first day of the month of the AC remand order.

Did not previously receive a determination of good cause but one is now found

Reinstate the earlier month of non-payment as a result of the initial cessation or disability hearing reconsideration.

7. Effectuating ALJ Remand Decision

Process the remand decision in accordance with the following chart:

If the claim is:

Then:

Approved

Effectuate ongoing SSI payments.

Denied or dismissed by ALJ or AC

The HO or AC will send a copy of the decision to the FO.

To stop benefits, the HO or AC will complete and send to the FO a termination memorandum (see DI 12095.172). Use Exhibit 3 if the ALJ issues the unfavorable decision; or Exhibit 4 if the ALJ recommended a decision and the AC issues the final unfavorable decision.

Upon receipt of an AC Exhibit 3 or Exhibit 4 memorandum the FO will terminate SBC.

REMINDER:  If the ALJ or AC denied or dismissed the claim, eligibility for SBC ends the month before the ALJ decision.

8. Follow Up for ALJ Remand Decisions

If no decision or dismissal is received within 120 days after the date of remand, the FO will request status from the HO.


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http://policy.ssa.gov/poms.nsf/lnx/0412027065