TN 32 (03-08)

DI 23535.001 Presumptive Disability/Presumptive Blindness (PD/PB) Eligibility, Authority, and Payment Issues

Citations:

Social Security Act -- Section 1631(a)(4)(B);

Regulations -- 20 C.F.R., Sections 416.536, 416.537, 416.931, 416.932, 416.933, 416.934,

A. Cases eligible for PD/PB

A claimant, including a child, applying for Supplemental Security Income (SSI) based on disability or blindness, may receive up to 6 months of payments prior to the final determination of disability or blindness if he/she is found to be presumptively disabled or blind and meets all other eligibility requirements. In order to make a PD or PB finding, the available evidence must reflect a high degree of probability that the claimant’s impairment or combination of impairments meets the Social Security Administration (SSA) definition of disability or blindness. In the case of readily observable impairments (e.g., amputation of a leg at the hip), a PD/PB finding is possible without medical or other evidence. In other situations, a PD/PB finding must be based on medical or non-medical evidence, which, although not sufficient for a formal determination of disability or blindness, are sufficient to establish a high degree of probability that the claimant is disabled or blind.

It is possible that a case meets more than one category of expedited cases, e.g., Compassionate Allowance (CAL), PD/PB, Terminal Illness (TERI), Quick Disability Decision (QDD), and Military Casualty/Wounded Warrior (MC/WW) cases.

For information regarding processing:

NOTE: Disability determination services (DDS) legacy systems may only identify one type of priority case when multiple priority flags are present (e.g., Suicide Risk, Terminal Illness (TERI), and PD). The disability examiner must review the certified electronic folder (CEF) or the paper modular disability folder (MDF) to ensure the case is developed and processed appropriately.

B. Cases not eligible for PD/PB

PD/PB provisions do not apply in the following situations:

  • Reconsideration or other administrative appeals;

  • Prerelease cases; or

  • Cases where the individual has a history of sustained work while severely impaired (but not at listing level severity), which terminated for reasons that were not obviously impairment related.

    NOTE: Prior technical denials for excess income that have been reversed on appeal are eligible for PD/PB, as there was not a previous determination based upon the medical evidence and are initial claims for the DDS.

C. Authority to make a PD/PB finding

  1. SSA field offices (FOs) are authorized to make a PD/PB finding for only those categories listed in DI 23535.005A.2.

  2. The DDS is authorized to make a PD/PB finding in any case in which there is a high degree of probability that the case will be allowed on formal determination (see DI 23535.010A.1.).

  3. If an individual's prior claim has been denied based on medical factors, the FO or DDS may make a PD/PB finding on a new initial claim only when the individual presents:

    1. Sufficient evidence of a worsening in his or her physical or mental condition; or

    2. New impairment(s) not previously assessed, which demonstrate(s) a strong likelihood that the subsequent claim will be allowed.

D. PD/PB payment issues

  1. Prior to the final determination of disability or blindness, an individual may receive up to six months of payments based on a PD/PB finding, if he or she meets all other eligibility requirements.

  2. Payments based on a PD/PB finding are not considered overpayments if it is later determined that the claimant is not disabled or blind unless:

    • The claim is disallowed due to ineligibility based on factors other than disability or blindness; or

    • It is subsequently determined that the claimant had excess resources or that the amount of payment was computed in error. In such cases, only the incorrect payment amount is considered an overpayment.

  3. If a claimant eligible for PD/PB benefits does not receive the payment(s), or it/they were returned, and the claimant subsequently receives a denial decision from the DDS, SSA may re-issue the PD/PB benefit(s) via one-time payment (OTP).


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0423535001
DI 23535.001 - Presumptive Disability/Presumptive Blindness (PD/PB) Eligibility, Authority, and Payment Issues - 11/09/2012
Batch run: 11/09/2012
Rev:11/09/2012