TN 2 (02-06)
DI 13050.030 Provisional Payments - Title XVI
A. Policy - Provisional Payment Eligibility
1. When an Individual is Eligible For Provisional Payments
An individual and eligible spouse who request(s) expedited reinstatement (EXR) may receive up to 6 months of provisional cash payments and Medicaid while a decision is being made on the request.
2. When an Individual is Not Eligible For Provisional Payments
Provisional benefits are not paid, or are stopped if already started, if it is determined the individual does not meet the requirements for EXR. An individual is not eligible for provisional payments when:
he or she was not previously eligible for DI, BI, DS, BS, or DC payments; or
his or her eligibility was not terminated due to earnings (or a combination of earned and unearned income); or
the request for reinstatement was not filed within the required 60-month time limit and good cause for late filing is not found; or
he or she is engaging in SGA in the month the request is filed; or
he or she does not meet eligibility factors in the month of filing the request (e.g., income, excess resources); or
he or she previously requested EXR for the same period of disability and received provisional payments for that request (see DI 13050.030A.3.); or
the DDS determines the individual does not meet the disability requirements for EXR.
An individual can elect to not receive provisional cash payments while the EXR request is being processed.
3. Paying Provisional Payments on a Subsequent EXR Request
Provisional benefits are generally not paid on an EXR request if an individual previously requested EXR for the same period of eligibility and received provisional benefits based on that request.
Provisional payments on a subsequent EXR request can be paid if the individual:
was approved for EXR on the previous request, and
completed the 24-month initial reinstatement period,
was terminated after completing the IRP due to earnings (or a combinations of earned and unearned income), and
filed a new request for reinstated benefits within 60 of months of that termination, or can show good cause for late filing.
B. Policy - Provisional Payment Amount
Compute the cash provisional payment in a month using normal SSI income counting rules and payment calculation methods, except no state supplementation is included in provisional payments. The cash payment is the amount that would be paid any SSI-eligible individual with the same type and amount of income and in the same living arrangement. Provisional payments are subject to change based on changes in income and living arrangements.
2. Concurrent EXR Requests
Apply windfall-offset provisions when provisional benefits are being paid under title II. Title II provisional benefits are considered income when calculating SSI payments.
Do not initiate recovery of an overpayment against provisional payments without the approval of the recipient.
REMINDER: State supplemental payments are not payable under the provisional payment provisions of expedited reinstatement.
C. Policy - Resources
Resources are not considered in determining the provisional payment amount. However, resources are considered in determining whether an individual is eligible for reinstatement. If an individual has excess resources in the month of the EXR request, the request for EXR will be denied and the individual is not eligible for provisional payments.
If the individual first has excess resources after the month of the EXR request, the excess resources will not affect the computation of the SSI provisional payments. If the individual is approved for EXR, the months of provisional payment where the individual should have been in non-payment status due to excess resources will be considered in calculating an overpayment.
D. Policy - Individual With Spouse
If the individual has a spouse who is potentially eligible for SSI, the spouse can also request expedited reinstatement. Compute the provisional payment using a couple's computation. If the spouse would be eligible based on blindness or a disability, a medical review is required for the spouse. If the spouse can be eligible based on age, the spouse can file an application and receive SSI provisional payments while awaiting the decision on the reinstatement request of his/her partner.
E. Policy - Provisional Payment Start And End Dates
1. Start Date
Provisional payments start with the month after the month the individual completes the request for EXR. Protective filing does not apply to provisional benefits. Provisional benefits begin the month after the month the individual submits the required documentation and signed EXR request per DI 13050.050B.2. The previous benefits must be terminated on the SSR before provisional payments can begin.
EXAMPLE: An individual contacts SSA about filing for EXR in 4/24/05 but does not return the signed application and requested documentation until 6/3/05. Provisional benefits will begin 7/05, the month after the month the individual completed his/her EXR request. The protective filing date of 4/05 will be used when the DDS makes the medical determination and establishes the month of eligibility for EXR benefits.
2. End Date
Provisional payments terminate with the earliest of:
The above dates represent the last month the provisional payment is payable.
F. Policy - Medicaid
In most states, eligibility for provisional payments also will allow the person to be eligible for Medicaid benefits (see SI 01730.010). Unless reinstated, the person's eligibility for Medicaid benefits based on provisional SSI payments ends when the provisional payments end.
G. Policy - Suspension/Terminating Events
Provisional payments will be suspended or terminated following normal benefit policies. Such suspension or termination events include prisoner suspense, institutionalization, alien suspense, etc. (See SI 02301.001 through SI 02301.330.) Do not resume provisional payments when a suspension event continues beyond the provisional payments ending month.
H. Policy - Appeals
Actions to pay, adjust or terminate provisional payments are not initial determinations that are subject to the administrative and judicial review (appeals) process. However, overpayment decisions related to provisional payments are subject to appeal. See DI 13050.085 for a discussion about appeals.
I. Procedure - Initiating Provisional Payments
Upon initial verification, if it appears the individual is eligible for EXR based on non-medical eligibility requirements; begin provisional payments through force due procedures. Establish a start date record using a SSA-450SI and follow the instructions below (see SM 01701.080 and SM 01005.020).
The start date month must be the month after the EXR request was filed, and no earlier than 02/01/01.
Enter a CG entry of EXRE.
Enter a code of PP with the diary date the last day of the month following the input month.
After establishing the start date record, use the Force Due process in Direct SSR Update to begin provisional payments. Refer to SM 01701.080 for screen completion instructions. State supplemental payments are not payable during the provisional payment period.
Issue a provisional payment start-up notice (see DI 13050.105).
J. Procedure - Adjusting or Stopping Provisional Payments
1. Adjusting Provisional Payments
If information is received that the person's income or living arrangement has changed, adjust the force payment if sufficient time remains in the provisional payment period.
2. Stopping Provisional Payments
A determination to deny a request for expedited reinstatement causes termination of provisional payments. The last payment due the individual, if no intervening termination occurs, is the month the EXR denial letter is mailed. Refer to SM 01701.080E. for provisional payment termination procedures for denial cases.
a. End of Six Month Provisional Period
Stop provisional payments. The last payment possible is for the sixth month after the EXR request was filed (see SM 01701.080).
b. Unfavorable Medical Decision
Input to stop provisional payments if they have not already been stopped and post the medical decision. The last payment month is the month the denial notice is sent to the individual (see SM 01701.080).
Issue a notice as warranted when provisional payments are changed or terminated. Do not provide appeal rights to the individual for provisional payment decisions (see DI 13050.105).
4. Individual Dies During Provisional Period
If the individual dies during a month that occurs after the EXR request is made but before a medical decision is made by the DDS, the FO will alert the DDS of the individual’s death. The DDS will not make a medical determination and will return the file to the FO. The FO will terminate provisional payments and Medicaid as of the month of death.
Follow the instructions in DI 13050.030K. and DI 13050.065B. to terminate provisional payments and process an EXR denial (see SM 01701.080). Refer to DI 13050.060E. to process an EXR allowance.