TN 5 (02-16)

DI 13050.025 Provisional Benefits for Title II Beneficiary

A. Provisional benefit eligibility

1. When a beneficiary is eligible for provisional benefits

A beneficiary who meets the requirements and completes a request for Expedited Reinstatement (EXR) may receive up to 6 months of provisional cash benefits and Medicare while we make a decision on his or her request. Medicare coverage based on the provisional benefit period is the same Medicare coverage the individual had prior to his or her termination.

2. When a beneficiary is not eligible for provisional benefits

A beneficiary is not eligible for provisional payments when one of the following applies:

  • he or she was not previously entitled to disability insurance benefits (DIB), childhood disability benefits (CDB), or disabled widow(er) benefits (DWB);

  • his or her entitlement did not terminate due to Substantial Gainful Activity (SGA);

  • he or she did not file the request for reinstatement within the required 60-month time limit and we did not find good cause for late filing;

  • he or she engaged in SGA in the month the request is filed;

  • an event has occurred that would preclude entitlement (CDB has married); or

  • DDS determines the beneficiary does not meet the disability requirements for EXR.

A beneficiary can decline provisional cash benefits, but still elect to receive Medicare coverage during the provisional benefit period.

NOTE: Provisional benefits are not payable to auxiliary claimants, other than a previously entitled DWB or CDB who is eligible and requests EXR. Provisional benefits are not payable to:

  • a beneficiary requesting EXR of CDB benefits on the record of a living number holder, if the number holder is not currently entitled; or

  • a DWB or CDB who does not meet other non-disability requirements (a CDB has married).

3. Paying provisional benefits on a subsequent EXR request

SSA does not pay provisional benefits on an EXR request if the beneficiary previously requested EXR for the same period of eligibility and received provisional benefits based on that request, regardless of how many months he or she received provisional payments on the previous request. However, we can pay provisional payments on a subsequent EXR request if the beneficiary:

  • was approved for EXR on a previous request;

  • completed the initial reinstatement period (IRP);

  • completed a trial work period (TWP);

  • completed his or her extended period of eligibility (EPE);

  • had his or her benefits later terminated due to SGA, and

  • files a new request for EXR within 60 months of that termination, or we can find good cause for late-filing.

Subsequent request example:

Ms. Jones requests EXR on 03/04/08 and we approve the request on 05/04/08. She receives 3 months of provisional payments before she is reentitled to disability benefits. She completes her IRP, TWP and EPE. After completing the EPE, Ms. Jones benefits terminate due to SGA in 01/15. On 04/12/15, Ms. Jones again files for EXR because she is no longer performing SGA. As Ms. Jones completed the IRP, TWP, and EPE on the new entitlement period, had her benefits terminated for SGA, and then filed a new EXR requests within 60 months of that termination, she is eligible to again request EXR and receive provisional benefits.

B. Provisional benefit amount

1. Benefit computations

Base the provisional benefit payment amount upon the payable benefit amount at the time the previous entitlement terminated, increased by intervening COLAs and recomputations. This is regardless of any other changes (such as overpayments, offsets, etc.). If the prior payable benefit was reduced due to offset or other reductions, base the provisional payment amount upon the prior reduced benefit payable. Apply current tax levies or garnishments to provisional payments in accordance with GN 02410.110 and, GN 02410.210. Apply any Medicare premium arrearages to provisional benefits. If an overpayment exists on the record, do not recover this against provisional benefits without the claimant’s written consent. If we award the EXR request, make adjustments for offsets (Workers Compensation/Public Disability Benefits [WC/PDB] and Government Pension Offset [GPO]), Windfall Elimination Provision (WEP), overpayments, and other payment issues with the first month of reinstated benefits.

2. Dual entitlement benefits

When a beneficiary requests reinstatement on one record and is currently receiving a title II benefit on another record, the provisional benefit is payable only if the provisional benefit amount is greater than the current benefit payable on the other record. If the current benefit amount is higher than the provisional benefit amount, no provisional benefits are payable. If a beneficiary requests EXR for more than one benefit, pay provisional benefits on the record that yields the highest benefit payable amount. (Compute the provisional benefits on different records independently based upon the prior benefit rate on that record with intervening cost of living adjustments [COLAs] and recomputations.)

3. Family maximum involved with DWB or CDB request

For DWB and CDB claimants, the payment of provisional benefits may cause the total benefits payable on the record to exceed the family maximum (FMAX). In such cases, pay the provisional benefit amount outside the FMAX and do not adjust the benefit amount for any auxiliary already entitled on the same record during the provisional benefit period.

C. Provisional benefit start month

1. When provisional benefits start

Provisional benefits are payable beginning with the month the beneficiary completes and submits the signed EXR request per DI 13050.045B.2, assuming benefits have not already been paid for that month. Do not use the protective filing date (if one exists) for provisional payment. We can only pay provisional benefits during the consecutive 6-month period that begins with the month the individual completes the EXR request.

Start month example: A beneficiary contacts SSA about filing for EXR on 04/24/15 but does not return the signed request forms until 06/03/15. Provisional benefits will begin 06/15, the month the individual completed his/her EXR request. We use the protective filing date of 04/24/15 as the month of filing documented in the Remarks section of the SSA-454 (see DI 13050.045B.2.b). The DDS uses the protective filing date to make the medical determination and establish the month of EXR entitlement, which may be up to 12 months prior to that date.

2. Previous benefits must be terminated

Provisional benefits cannot start until the previous benefits terminate and the Master Beneficiary Record (MBR) LAF Code is T6, T8, U or X7. If we made a determination to terminate the previous benefit but it has not input to the MBR, the FO should contact the Payment Center (PC) to expedite the termination in order to begin provisional benefits. Use the exclusion case procedures described in DI 13050.025I.3 to expedite the previous benefit termination. We cannot pay provisional benefits for any month in which the beneficiary has already received the same type of benefit payment on the same entitlement.

EXAMPLE: On 4/18/14, SSA contacts Mr. Jones to tell him that they will terminate his disability benefits due to performing SGA. The benefit termination month (BTM) is 09/13. Mr. Jones contacts SSA on 04/29/14 to say that he has not worked for the last 3 months due to his disability and submits his request for EXR. Though we determined to terminate Mr. Jones benefits, an MBR review shows that the benefit termination has not yet been effectuated. The FO contacts the PC to expedite the termination. Benefits terminate ten days later (05/09/14). Mr. Jones will receive his first month of provisional benefits for 05/14, since he received a benefit payment for 04/14. DDS will use protective filing date of 04/29/14 from the Remarks section of the SSA-454 to make the medical determination.

D. Provisional benefit end month

Payment of provisional benefits ends with the earliest of:

  • the month SSA makes a determination and issues the notice regarding the individual's EXR request;

  • the month the beneficiary works and performs SGA;

  • the month before the beneficiary attains full retirement age;

  • the month before the beneficiary dies; or

  • the 5th month following the month the beneficiary completed the EXR request.

NOTE: These months are the last month the provisional payment is payable. Therefore, if a beneficiary begins SGA in 04/2015, 04/2015 is the last possible month of provisional benefits.

E. Suspension and terminating events

Suspend or terminate provisional benefits following normal benefit policies. Such suspension or termination events include:

  • prisoner suspension,

  • alien suspension, and

  • marriage of a CDB

For a discussion of suspension and termination events, see GN 02602.005, RS 00203.030, RS 00203.035, and RS 00207.002. Provisional benefits will not resume when a suspension event continues beyond the provisional benefit period ending month.

F. Medicare entitlement

A beneficiary previously entitled to disability benefits who requests benefit reinstatement also receives Medicare coverage during the provisional benefit period. It is important to understand the type of Medicare coverage that exists when the beneficiary enters the provisional benefit period (Disabled Working Individual [DWI], Extended Medicare, End Stage Renal Disease [ESRD]) as the DDS medical determination affects the types of coverage differently. For instructions regarding Medicare coverage and termination as they relate to EXR, see HI 00801.164 to HI 00801.167 and DI 13050.070.

G. Appeals process

Actions to pay, adjust or terminate provisional benefits are not initial determinations and are not subject to the administrative and judicial review (appeals) process. However, overpayment decisions relating to provisional benefits are subject to review. For a discussion about appeals, see DI 13050.085.

H. Special situations

1. Beneficiary is already entitled to, or eligible for, another title II retirement, auxiliary or survivor benefit

Pay the higher amount of either the title II benefit the beneficiary already receives or the provisional benefit payable. Regardless of the benefit actually paid during the provisional period, afford Medicare entitlement to the beneficiary.

If the beneficiary receives reduced benefits based on an application with a date of entitlement before attainment of full retirement age, do not count months in which he or she receives provisional disability benefits towards reducing the reduction factor.

If provisional benefits terminate, resume the other benefit, if still payable.

2. Beneficiary is eligible for SSI provisional benefits

Regular payment provisions apply. Consider windfall offset. Title II provisional benefits are income for SSI computation purposes. The beneficiary must file a separate request for reinstatement under title XVI.

3. Beneficiary attains full retirement age (FRA) during the provisional benefit period

Provisional disability benefits terminate when a beneficiary attains FRA. Provisional benefits do not automatically revert to an aged benefit at FRA. If the beneficiary wishes to receive aged benefits, he or she must file an application, or already be entitled to a benefit that will automatically convert to an aged benefit at full retirement age (regular widow's benefit or retirement).

4. Beneficiary is entitled to provisional benefits for multiple title II benefits

A beneficiary must file separate EXR requests for multiple entitlement situations. Evaluate each request against the EXR requirements and process accordingly. Pay provisional benefits on the record that yields the highest benefit payable.

5. Beneficiary has appeal pending on prior claim denial, or on termination of prior entitlement

The appeal of a prior claim denial, or termination appeal, has no effect on the beneficiary’s eligibility for EXR. The beneficiary can receive provisional benefits and reinstate through EXR, if the beneficiary meets EXR eligibility requirements in the month of the EXR request.

I. Initiating provisional benefits

If the beneficiary is eligible for EXR based on non-medical eligibility requirements, begin provisional benefits via POS (do not use the Critical Payment System [CPS] to initiate provisional payments; for non-receipt of EXR provisional payments, see DI 13050.100). If subsequent development determines that EXR does not meet non-medical requirements, see instructions in MSOM T2PE 003.024.

1. Using POS to start provisional benefits

Input the request for provisional benefits on the Provisional Payment (PEPP) screen of the title II Post-entitlement Online System (POS). Instructions are in MSOM T2PE 003.040. Follow these steps to access the PEPP screen:

  1. Select option 2, title II/PE, on the SSA MAIN menu and press Enter.

  2. On the POS Menu (PEMU) screen, select 1 to establish and complete the required fields, press Enter.

  3. On the Postentitlement Selection List (PESL) screen select item 7 (Provisional Payments) and item 1 (Addr/Dir Dep/Tel) for the appropriate BIC, press Enter.

  4. On the Post Entitlement Address (PEAD) screen, enter any needed changes to the beneficiary’s address, bank data, or telephone number propagated to the PEAD screen from the MBR. If no changes are necessary and all information is correct, press enter to advance to the PEPP screen.

  5. On the PEPP screen, enter the date of the EXR request in MMYY format, any remarks that may be needed, and press Enter.

2. Processing exception cases for provisional benefits

Some cases require processing in the PC to start provisional benefits. The following situations will generate an exception alert in the PC that requires manual processing:

  • concurrent title II/title XVI cases and a PMA check is payable;

  • DWB and CDB cases in which there are other entitled auxiliaries on the same record; and

  • cases where the individual requesting EXR already is entitled to another title II benefit

If the direct input does not process, do not attempt to re-input through POS. Check PCACS for an Action Control Record (ACR) with TOELs DIPROV PAYMENT. It may take up to three business days for the ACR to appear in PCACS. If the ACR does not appear in PCACS after three business days, contact the PC of jurisdiction.

If the ACR is present in PCACS, tickle the case for 15 business days to allow for PC processing. If the MBR does not update after 15 business days, contact the PC of jurisdiction and tickle the case for 15 days for follow up.

To contact the PC of jurisdiction:

  • For PSC 1-6 cases, follow the locally established procedures for resolution of high priority cases, or send a 2560HP. Enter the remark “Do not place in backlog”

  • For PC 7 cases, send an email to ||OCO ODO PITAG requesting status

If the MBR does not update after the second 15-day tickle or if a dire need/adverse public relation situation exists, FO’s should use the Manager-to-Manager process to contact the PC per GN 01070.228. Contact PC7 by selecting PROGRAM INTEGRITY TAG with the subject line Manager to Manager.

3. Processing exclusion cases for provisional benefits

Exclusion cases do not process through a POS input, and requires manual action by the PC. Some examples of exclusion cases are:

  • the provisional benefit is not payable in the first month of the provisional period (payment is suspended) or

  • the EXR request date is more than 60 months after the previous termination (good cause found for late filing)

Do not use CPS to start provisional payments, as Supplementary Medical Insurance (SMI) premiums will not be withheld and may result in a termination of SMI due to non-payment of premiums. Requests for initiation of provisional payments are high priority actions.

  • Send requests for PC 7 to initiate provisional payments for exclusion cases to ||OCO ODO PITAG.

  • For PSC 1-6 cases, follow the locally established procedures for resolution of high priority actions, or send a 2560HP. Enter the remark “Do not place in backlog”:

Tickle for 15 days to follow up. If the MBR does not update after the 15-day follow up tickle expires or if a dire need/adverse public relation situation exists, FO’s should use the Manager-to-Manager process to contact the PCs per GN 01070.228. Contact PC7 by selecting PROGRAM INTEGRITY TAG with the subject line Manager to Manager.

J. Procedure for terminating provisional benefits

When the provisional benefit period ends, provisional benefits and Medicare entitlement based solely on the provisional benefit period must terminate, see HI 00801.165. Medicare entitlement based on age, ESRD, or extended Medicare does not terminate at the end of the provisional benefit period. For a detailed discussion about Medicare in relation to EXR determinations, see DI 13050.070.

1. Terminating benefits due to substantial gainful activity (SGA)

The performance of SGA during the provisional benefit period terminates provisional benefits.

  • Develop work activity during the provisional benefit period.

  • Document the work on form SSA-820 or SSA-821 and record the determination on form SSA-823 and fax into eView or non-disability repository application (NDRED).

  • Notify the Disability Determination Services (DDS) examiner by telephone of the work and SGA finding.

  • Forward the documentation to the DDS.

  • If the beneficiary has engaged in SGA, terminate provisional benefits through POS input, see MSOM T2PE 003.024.

  • The last month of provisional benefits payable is the first month of SGA. Provisional benefits do not resume after termination due to SGA.

  • For cases in PSC 1-6 jurisdiction, send an MDW to request action on Medicare termination issues, if necessary.

  • For cases in PC 7 jurisdiction, send an email to ||OCO ODO PITAG to request termination of Medicare, if necessary.

If the beneficiary performs SGA in the month of the EXR request, recall the folder from DDS and process a FO jurisdiction technical denial as outlined in DI 13050.045E.

2. Terminating provisional benefits due to medical denial determination

Terminate provisional benefits (if currently being paid) when DDS makes a medical determination to deny expedited reinstatement. The last month provisional benefits are payable is the month the EXR denial notice is mailed. See DI 13050.070 to determine how a medical determination may affect Medicare coverage. To stop provisional payments input the medical decision via POS, refer to DI 13050.065B.3.

3. Terminating benefits due to full retirement age (FRA)

When a beneficiary reaches FRA during the