BASIC (01-02)

DI 13050.035 Reinstatement Determination - Title II

A. Policy - Individual Does Not Meet Requirements For Expedited Reinstatement

Deny a request for expedited reinstatement (EXR) when the requirements in DI 13050.001B. are not met (also see in DI 13050.015A.). Send notice of the denial determination to the individual and, if started, stop provisional benefits and Medicare (if based solely on provisional benefits). The last provisional benefit payable is for the month the denial notice is sent, if not stopped earlier for another reason.

The request for reinstatement can be used as protective filing for a new application if the individual chooses to file a new application. (See DI 13050.015C.2.)

B. Policy - Unfavorable Medical Decision

If SSA determines that the individual is not entitled to reinstatement based on application of the same as or related or medical improvement review standard (MIRS), send notice to the individual explaining the reason the reinstatement request is denied. The last provisional benefit payable is for the month the denial notice is sent, if not stopped earlier for another reason.

Refer to HI 00801.165 for the effect an unfavorable medical decision has on Medicare entitlement.

C. Policy - Favorable Medical Decision

1. Retroactivity

If it is found the individual is under a disability and entitled to reinstatement, benefits can be reinstated retroactively for up to 12 months before the EXR request date (but not earlier than January 1, 2001) provided all factors of entitlement are met. No retroactive payment is due for any month that the person engaged in SGA or did not perform SGA for a reason not related to his/her disabling impairment. Normal suspension and terminating events apply to all reinstated benefits. Offset calculated reinstated benefits due by provisional payments made.

2. Auxiliary Benefits

Auxiliaries previously entitled on a reinstated number holder's record, who continue to meet entitlement requirements, will be reinstated to benefits with the first month of reinstatement for the disabled number holder. A new application must be filed to reinstate entitlement. If auxiliary entitlement was based on the auxiliary's disability, a medical review must be done before the auxiliary can be reinstated.

3. 24-Month Initial Reinstatement Period (IRP)

The 24-month initial reinstatement period is the months between the initial EXR entitlement month and the attainment of qualifying months that make the individual eligible for a TWP. Reinstated benefits are not payable for any month the individual performs SGA during the IRP. SGA during the IRP is determined on a monthly basis using normal work incentives (IRWE, subsidy, etc.) that are applicable during the EPE. Since SGA is computed on a monthly basis, work incentives not used in an EPE SGA determination (income averaging, unsuccessful work attempt) do not apply to the IRP. SGA for blind individuals is based on blindness provisions. Benefits for auxiliaries also are suspended when a wage earner is suspended during the IRP. Medicare coverage continues during SGA months.

4. After IRP is Completed

The IRP is completed when the individual has completed a total of 24 months of entitlement in which the work activity is below the SGA level. After an individual's SGA status would allow payment of 24-months of, not necessarily consecutive, reinstated benefits (which includes the provisional benefit period and any period of retroactivity, offset months, deduction, suspense and overpayment collection months) the individual is entitled to:

• a new 9-month trial work period;

• a new 36-month reinstatement period (extended period of eligibility);

• a new 60-month period to file an EXR request if the reinstated benefits terminate due to SGA earnings; and

• a new period of extended Medicare coverage.

D. Policy - Reinstated Benefit Termination

Entitlement to reinstated benefits ends with the month before the earliest of:

• the 3^rd month following the month in which the individual's disability ceases for medical reasons; or

• the disability benefit cessation date (DBC) that is applicable due to engaging in SGA after the EPE ends; or

• the month in which the individual attains full retirement age; or

• the month in which the individual dies; or

• the month benefits terminate for other reasons (CDB marries, etc.).

E. Procedure - Documenting the Initial Reinstatement Period

1. General

Document an SGA determination during the IRP on a SSA-833, (Cessation or Continuance Disability Determination or Transmittal). Since SGA level work during the provisional benefit period results in a termination of provisional payments, a SSA-833 is not required. However, once an individual is approved for EXR, a SSA-833 is needed to document the SGA/S7 suspense and reinstatement months. Refer to MSOM T2PE 003.024 (PEC1 screen, reason 7) and MSOM T2PE 003.037 for instructions relating to how to input IRP suspense and reinstatement months.

2. Completing the SSA-833

Complete the SSA-833 in the normal fashion for a SGA determination during the extended period of eligibility (EPE), with the following considerations.

1. Block 5; show the original claim date of onset.

2. Block 9; check “Disability” and block “A” unless the EXR-IRP decision is being made in conjunction with a cessation decision.

3. Annotate Block 24 “EXR-IRP SGA” and record the months of SGA and non-SGA. If there is not sufficient space in the block to record the determination, use a continuation sheet (check block 13). This data is recorded in the same manner as EPE data.

   • IRP Begin Month: Show the month benefits were reinstated.

   • IRP Suspense Month: Show the first month in the IRP the individual engages in SGA.

   • IRP Reinstatement Allowed: Show the first month of non-SGA after a suspense month.

   • IRP Suspense After Reinstatement: Show the first month of SGA after a reinstatement.

   • IRP End Month: Show the last month of the IRP. This is the 24^th month the individual did not engage in SGA after the IRP Begin Month. This date is needed to document the individual's reentry into the regular work incentive provisions (TWP/EPE/Extended Medicare).

   NOTE: There can be multiple “IRP Reinstatement” and “IRP Suspense After Reinstatement” months because SGA during the IRP is being calculated on a month-by-month basis. This can result in multiple SSA-833s prepared. When an SSA-833 is completed, use the remarks area of the MBR to record total IRP months (non-SGA months) credited to that point.