TN 2 (02-06)

DI 13050.020 Filing Considerations - Expedited Reinstatement Versus Initial Claim

A. Background

When previously entitled individuals notify SSA that they are no longer performing substantial gainful activity (SGA), they must be informed of all of their filing options, including the option to request EXR or file a new initial claim. Most individuals who meet the requirements for EXR also meet the requirements for an initial claim.

It is not intended that an individual should pursue both EXR and an initial claim at the same time. The filing options available to the individual, and the advantages of each option, should be fully explained to the individual. In most situations, filing EXR will normally be most advantageous. However, there are situations in which filing an initial claim may be more advantageous.

The individual should decide whether he/she wishes to pursue EXR or a new initial claim. However, if the claimant insists on filing both actions at the same time, refer to DI 13050.090.

B. Policy - Filing Election

1. Applicant Decision

When previously entitled individuals notify SSA that they are no longer performing substantial gainful activity (SGA), they must be informed of all of their filing options, including requesting EXR or filing a new initial claim. Most individuals who meet the eligibility requirements for EXR also meet the eligibility requirements to file an initial claim.

It is not intended that an individual should pursue EXR and an initial claim at the same time. Fully explain the requirements of each filing option available, as well as the advantages of each option. In most situations, filing EXR will be most advantageous. However, there are situations in which filing an initial claim may be more advantageous (see DI 13050.020C. and DI 13050.020D. for a more detailed discussion).

The individual should decide whether he wishes to pursue EXR or a new initial claim. If the claimant insists on filing both actions at the same time refer to DI 13050.090.

NOTE: If the beneficiary is a Benefit Offset National Demonstration (BOND) participant, see DI 60099.035A.2 for BOND processing rules.

2. Individual Chooses to File a New Initial Claim

When an individual who appears to meet the qualifications for EXR chooses to file a new initial claim instead of requesting EXR, the FO must take the following actions:

Close out any existing protective filing date for EXR per DI 13050.015 and GN 00204.012. As noted in DI 13050.015C.2.d., a protective filing date for EXR also serves as protective filing for a new initial claim.

Include in the “Remarks” section of the initial claim application that will be signed by the individual that he or she has elected to file a new claim instead of EXR. This documentation establishes that the individual was provided the opportunity to request EXR. This statement should:

  • Indicate the individual was advised he/she could request EXR, and

  • Has chosen to instead file a new initial claim, and

  • Explain why he/she decided to file the new claim rather than an EXR request. If the individual does not give a reason for the decision, state that the individual did not want to give a reason.

EXAMPLE: “I was advised I could request expedited reinstatement, but I have chosen to file a new initial disability application because my benefit amount would be higher.”

3. Individual Is Current SSI Recipient

A SSI recipient is required to file for all other possible benefits. If a SSI recipient meets the requirements to request EXR for a title II benefit he or she is required to pursue the EXR request.

If a current SSI recipient could file either an EXR request or an initial claim for the same title II benefit, he or she must file for the benefit with the most retroactivity. If EXR does not provide the earliest month of entitlement, or if the entitlement dates are the same for EXR and an initial claim, and the EXR benefit amount is not higher, then the individual will be required to file for both EXR and the initial claim. This will protect the EXR filing if the initial claim is denied. If both EXR and the initial claim are approved, the individual will be required to accept the benefit that provides the earliest month of entitlement or, if entitlement dates are the same, accept the benefit that would yield the higher benefit payment. (See SI 00510.001D.1.a.)

If the recipient could request EXR for multiple benefits, use the guidelines in SI 00510.001 to SI 00510.030.

C. Policy - Title II

The following issues should be considered when an individual decides whether to request EXR or file a new initial claim. The issues below are not necessarily a list of all the considerations an individual may have and each individual's circumstances will vary. The FO should thoroughly review each of these considerations with the individual before he or she decides whether to request EXR or file a new initial claim.

1. Benefit Computation

The PIA computed based on a new claim may differ from the PIA (plus COLAs and AERO adjustments) that is computed for EXR from the previous reinstated entitlement. This is especially true if the individual had significantly higher or lower earnings in the period following termination. A computation must be done to compare the new PIA with the reinstatement PIA.

2. Medicare Coverage

A denial based on MIRS medical improvement of an EXR request terminates an individual's Medicare coverage (other than ESRD) even though he/she had Medicare coverage before requesting reinstatement. This occurs because the second step of the medical review for a reinstatement request follows the guidelines of the Medical Improvement Review Standard (MIRS) and MIRS is used as a basis to evaluate continued eligibility for Medicare coverage. However, a medical denial of an initial claim may not terminate Medicare coverage. See DI 13050.070 for more information regarding EXR denials and Medicare termination.

3. Benefit Retroactivity

A new disability claim may have as much as 12 months of retroactivity for benefit entitlement purposes. Reinstated benefits can also have up to 12 months of retroactivity from the request month if the individual is found to be entitled to EXR.

If the individual decides to request EXR, use SSA-820 or 821 to document SGA and record the SGA determination on the SSA-823 (see DI 13050.045C.1.b.). The DDS must have this information to consider retroactivity and establish the proper month of entitlement. See DI 13050.060A for further discussion.

Retroactive benefits cannot be reinstated via EXR for a month prior to January 2001.

NOTE: The 6-month limitation on retroactivity for an RSI childhood disability beneficiary (CDB) (see GN 00204.030B.5.) does not apply to EXR. CDB beneficiaries who are approved for EXR are eligible for up to 12 months of retroactive benefits, assuming all other requirements are met.

4. Insured Status

A new initial claim requires that the NH meet insured status for that claim. EXR does not have this requirement as it is based on the prior entitlement.

5. Return To Work Issues

In an initial claim, work in the retroactive period that is above the SGA monthly level may be determined to be an unsuccessful work attempt, thus allowing payment for those months. In EXR, a monthly benefit within the 24-month initial reinstatement period (IRP) (which would include retroactive months) is not payable if work in that month is SGA. (See DI 13050.066A.)

Also, in an initial claim, a return to SGA within 12 months of the onset can cause the claim to be denied. In EXR, if the return to SGA is after the EXR request month, thus allowing at least one month of reinstated benefits, the work activity does not cause a denial. The individual is placed in suspense for SGA months.

In an initial claim, the individual must meet the medical duration requirements. In EXR, the individual need only to not have engaged in SGA in the month the request is filed and then, for Title II purposes, can possibly be entitled in an individual non-SGA month in the retroactive period.

6. The 24-Month Initial Reinstatement Period (IRP)

The IRP allows payment for non-SGA months in up to 24 total months before the individual reenters regular work provisions (TWP/EPE). Benefits suspended or withheld for reasons other than SGA (such as offsets or overpayments) may be counted toward this 24-month period. Medicare coverage continues throughout, including the SGA months. See DI 13050.066 for a complete discussion of the IRP.

7. Protective Writing

If an EXR request is denied, it can then serve as a protective writing for a new initial claim. However, if an initial claim is denied it does not protect EXR filing. This could be an important consideration if more than 12 months retroactivity is possible under both filing options.

8. Medicare Issue

The extended period of Medicare begins with the first month of SGA after the 15th month of the EPE. Under EXR an individual cannot enter the TWP, EPE and extended Medicare period until he or she has completed the IRP. EXR can result in a substantial lengthening of Medicare coverage when an individual returns to ongoing SGA during the IRP.

9. Statutory Blindness

The general EXR provisions apply to disability benefits based on statutory blindness in the same way they apply to other disability benefits. However, in the initial claims process an individual in a freeze period is not normally required to undergo a new medical review to reestablish cash benefits. Under EXR, the individual is required to undergo the EXR same as or related and MIRS review process (see DI 26001.005 regarding the disability freeze status).

10. Ticket to Work

If the beneficiary is using a Ticket to Work and either the new claim or the EXR request is approved, a new period of disability entitlement or eligibility will be established. As a result, that ticket will terminate and the plan and agreement with the provider will no longer be in effect. A new ticket will be issued, which the beneficiary may assign by entering into a new agreement with the previous provider or a new provider. For policies on ticket terminations, see DI 55002.055.

D. Policy - Title XVI

1. Protective Filing

A protective filing could allow SSI entitlement retroactively to the protective filing date. Under no circumstances can EXR payments be made for a period before February 2001. Protective filing does not apply to the start month for provisional payments. See DI 13050.030E.

2. Substantial Gainful Activity

Returning to work while a determination is pending could cause a SSI initial claim to be denied (medical duration requirements). Under EXR, work activity after the month the EXR request is filed is treated as earnings under normal SSI computation procedures.

3. The 24-month Initial Reinstatement Period (IRP)

The IRP provides that payment for 24 total months must be made before the individual can again qualify for reinstatement through EXR. Months of eligibility to 1619(b) are counted towards the IRP.

4. Protective Writing

If an EXR request is denied, it will then serve as a protective writing for a new initial claim. However, if an initial claim is denied it does not protect EXR filing.

5. Ticket to Work

If the individual is using a Ticket to Work and either the new claim or the EXR request is approved, a new period of disability entitlement or eligibility is established. As a result, that ticket terminates and the plan and agreement with the provider is no longer in effect. A new ticket is issued