BASIC (03-04)

DI 28095.020 Multiple Notices

The notices for concurrent title II/title XVI claims continuing disability review (CDR) cases are governed by the same principles which apply to each claim separately. In concurrent CDR title II/title XVI cessations, it will be necessary to prepare a separate notice and personalized explanation for each claim. (See DI 26530.001 for preparation of the personalized explanation.), unless the cessation fits one of the following situations:

  • Medical Improvement

  • Group I Exceptions

  • Group II Exceptions

If the cessation fits one of the situations listed above, a concurrent cessation notice may be prepared. (Exhibits 1, 2, and 3 contain sample language for each respective situation.)

When separate notices are prepared for concurrent title II/title XVI claims each notice must contain a reference to the other claim. Paragraph 841 is the title II disclaimer paragraph to be included on the title XVI notice (when not preprinted on the form letter). Paragraph 842 is the title XVI disclaimer paragraph to be included on the title II notice (when not preprinted).

  

Exhibit 1

CONCURRENT CDR CESSATION NOTICE MEDICAL

IMPROVEMENT

SOCIAL SECURITY ADMINISTRATION

Retirement, Survivors and Disability Insurance

Supplemental Security Income

Notice of Disability Cessation

                                                                                                                             Date

                                                                                                                             123-00-6789 HA

Claimant Name

Address

City, State Zip

We are writing to let you know that we have made a decision on (1) Social Security and Supplemental Security Income (SSI) cases. After reviewing all of the information carefully, we have decided that (2) health has improved since we last reviewed (3) case. And (4) now able to work. This means that (5) benefits will stop.

Fill-ins:

  1. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  2. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  3. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  4. Choice 1:  you are

    Choice 2:  he is

    Choice 3:  she is

  5. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

When (1) Payment Will Stop

Fill-ins:

  1. Choice 1:  Your

    Choice 2:  Disability claimant (possessive)

(1) no longer disabled as of (2) . If (3) getting payments, (4) will receive them for that month and the next 2 months, and (5) last payment will be for (6) .

Fill-ins:

  1. Choice 1:  You are

    Choice 2:  He is

    Choice 3:  She is

  2. Cessation month and year

  3. Choice 1:  you are

    Choice 2:  he is

    Choice 3:  she is

  4. Choice 1:  you

    Choice 2:  he

    Choice 3:  she

  5. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  6. Last month and year of entitlement/eligibility

The Decision On (1) Case

PDN Portion of Notice (2)

Fill-ins:

  1. Choice 1:  Your

    Choice 2:  Disability claimant (possessive)

  2. Personalized language

Information About (1) Medicare and Medicaid

Fill-ins:

  1. Choice 1:  Your

    Choice 2:  Disability claimant (possessive)

If (1) Medicare, (2) coverage will end the last day of (3) .

For information about any change in (4) Medicaid eligibility caused by this action, you should get in touch with (5) .

Fill-ins:

  1. Choice 1:  you have

    Choice 2:  he has

    Choice 3:  she has

  2. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  3. Last month and year of Medicare coverage

  4. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  5. Name of State Agency

If You Disagree With The Decision

If you disagree with this decision, you have the right to appeal. We will review your case and consider any new facts you have. A person who did not make the first decision will decide your case.

  • You have 60 days to ask for an appeal.

  • The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

  • You must have a good reason for waiting more than 60 days to ask for an appeal.

  • You have to ask for an appeal in writing. We will ask you to sign a Form SSA-789-U4, called "Request for Reconsideration – Disability Cessation." Contact one of our offices if you want help.

Please read the enclosed pamphlet, "Your Right to Question the Decision to Stop Your Disability Benefits." It contains more information about the appeal.

Appeal In 10 Days To Keep Getting (1) Payment And Medicare

Fill-ins:

  1. Choice 1: Your

    Choice 2:  Disability claimant (possessive)

You have only 10 days to ask us to continue (1) payments during your appeal.

  • The 10 days start the day after you get this letter.

  • You can ask us to keep paying (2) and (3) family.

  • Also, if you ask us to keep paying (4) and (5) covered by Medicare, (6) Medicare will continue.

  • f you lose your appeal, you might have to pay back some or all of this money, but you will not have to pay back Medicare.

Fill-ins:

  1. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  2. Choice 1:  you

    Choice 2:  him

    Choice 3:  her

  3. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  4. Choice 1:  you

    Choice 2:  him

    Choice 3:  her

  5. Choice 1:  you are

    Choice 2:  he is

    Choice 3:  she is

  6. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

How The Appeal Works

A Disability Hearing Officer will decide your appeal. We will call this person a DHO in the rest of our letter. The DHO will meet with you before making the decision on your appeal. The meeting works like this.

  • The DHO will write you about the time and place for the meeting.

  • You can look at (1) file before the meeting.

  • You can tell the DHO why you think (2) still disabled. You can give the DHO more facts.

    And you can bring people to say why (3) disabled.

  • You can have the DHO ask people to come to the meeting and bring important papers. You can question these people at the meeting.

  • You do not have to go to the meeting in person. If you do not want to go, you can give the DHO more facts you may have. The DHO will decide your case using these facts, and what is now in (4) file. But if you go to the meeting, it may help the DHO decide your case.

Fill-ins:

  1. Choice 1:  your

    Choice 2:  Disability claimant (possessive)

  2. Choice 1:  your are

    Choice 2:  he is

    Choice 3:  she is

  3. Choice 1:  you are

    Choice 2:  he is

    Choice 3:  she is

  4. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

If You Want Help With Your Appeal

You can have a friend, lawyer, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a lawyer, we will withhold up to 25 percent of any past due Social Security benefits to pay toward the fee.

If (1) Health Gets Worse

Fill-ins:

  1. Choice 1:  Your

    Choice 2:  Disability claimant (possessive)

If (1) health gets worse and you feel that (2) disabled again, please get in touch with us. (3) may be able to get benefits again.

Fill-ins:

  1. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  2. Choice 1:  you are

    Choice 2:  he is

    Choice 3:  she is

  3. Choice 1:  You

    Choice 2:  He

    Choice 3:  She

If You Have Any Questions

If you have any questions, call us toll-free at 1-800-772-1213, or call your local Social Security office at [FO phone number from DOORS]. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

[Field Office Address, City, ST, ZIP]

If you do call or visit an office, please bring this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

Regional Commissioner

Enclosure:

  

Exhibit 2

CONCURRENT CDR CESSATION NOTICE – GROUP I EXCEPTION

SOCIAL SECURITY ADMINISTRATION

Retirement, Survivors and Disability Insurance

Supplemental Security Income

Notice of Disability Cessation

                                                                                                                           Date

                                                                                                                           123-00-6789 HA

Claimant Name

Address

City, State Zip

We are writing to let you know that we have made a decision on (1) Social Security and Supplemental Security Income (SSI) cases. After reviewing all of the information carefully, we have decided that (2) able to work. This means that (3) benefits will stop.

Fill-ins:

  1. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  2. Choice 1:  you are

    Choice 2:  he is

    Choice 3:  she is

  3. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

When (1) Payment Will Stop

Fill-ins:

  1. Choice 1:  Your

    Choice 2:  Disability claimant (possessive)

(1) no longer disabled as of (2) . If (3) getting payments, (4) will receive them for that month and the next 2 months, and (5) last payment will be for (6) .

Fill-ins:

  1. Choice 1:  You are

    Choice 2:  He is

    Choice 3:  She is

  2. Cessation month and year

  3. Choice 1:  you are

    Choice 2:  he is

    Choice 3:  she is

  4. Choice 1:  you

    Choice 2:  he

    Choice 3:  she

  5. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  6. Last month and year of entitlement/eligibility

The Decision On (1) Case

PDN Portion of Notice (2)

Fill-ins:

  1. Choice 1:  Your

    Choice 2:  Disability claimant (possessive)

  2. Personalized language

Information About (1) Medicare and Medicaid

Fill-ins:

  1. Choice 1:  Your

    Choice 2:  Disability claimant (possessive)

If (1) Medicare, (2) coverage will end the last day of (3) .

For information about any change in (4) Medicaid eligibility caused by this action, you should get in touch with (5) .

Fill-ins:

  1. Choice 1:  you have

    Choice 2:  he has

    Choice 3:  she has

  2. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  3. Last month and year of Medicare coverage

  4. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  5. Name of State Agency

If You Disagree With The Decision

If you disagree with this decision, you have the right to appeal. We will review your case and consider any new facts you have. A person who did not make the first decision will decide your case.

  • You have 60 days to ask for an appeal.

  • The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

  • You must have a good reason for waiting more than 60 days to ask for an appeal

  • You have to ask for an appeal in writing. We will ask you to sign a Form SSA-789-U4, called "Request for Reconsideration – Disability Cessation." Contact one of our offices if you want help.

Please read the enclosed pamphlet, "Your Right to Question the Decision to Stop Your Disability Benefits." It contains more information about the appeal.

Appeal In 10 Days To Keep Getting (1) Payment And Medicare

Fill-ins:

  1. Choice 1:  Your

    Choice 2:  Disability claimant (possessive)

You have only 10 days to ask us to continue (1) payments during your appeal.

  • The 10 days start the day after you get this letter.

  • You can ask us to keep paying (2) and (3) family.

  • Also, if you ask us to keep paying (4) and (5) covered by Medicare, (6) Medicare will continue.

  • If you lose your appeal, you might have to pay back some or all of this money, but you will not have to pay back Medicare.

Fill-ins:

  1. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  2. Choice 1:  you

    Choice 2:  him

    Choice 3:  her

  3. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  4. Choice 1:  you

    Choice 2:  him

    Choice 3:  her

  5. Choice 1:  you are

    Choice 2:  he is

    Choice 3:  she is

  6. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

How The Appeal Works

A Disability Hearing Officer will decide your appeal. We will call this person a DHO in the rest of our letter. The DHO will meet with you before making the decision on your appeal. The meeting works like this.

  • The DHO will write you about the time and place for the meeting.

  • You can look at (1) file before the meeting.

  • You can tell the DHO why you think (2) still disabled. You can give the DHO more facts. And you can bring people to say why (3) disabled.

  • You can have the DHO ask people to come to the meeting and bring important papers. You can question these people at the meeting.

  • You do not have to go to the meeting in person. If you do not want to go, you can give the DHO more facts you may have. The DHO will decide your case using these facts, and what is now in (4) file. But if you go to the meeting, it may help the DHO decide your case.

Fill-ins:

  1. Choice 1:  your

    Choice 2:  Disability claimant (possessive)

  2. Choice 1:  your are

    Choice 2:  he is

    Choice 3:  she is

  3. Choice 1:  you are

    Choice 2:  he is

    Choice 3:  she is

  4. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

If You Want Help With Your Appeal

You can have a friend, lawyer, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. Your local Social Security office has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before he or she can collect it. And if you hire a lawyer, we will withhold up to 25 percent of any past due Social Security benefits to pay toward the fee.

If (1) Health Gets Worse

Fill-ins:

  1. Choice 1:  Your

    Choice 2:  Disability claimant (possessive)

If (1) health gets worse and you feel that (2) disabled again, please get in touch with us. (3) may be able to get benefits again.

Fill-ins:

  1. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  2. Choice 1:  you are

    Choice 2:  he is

    Choice 3:  she is

  3. Choice 1:  You

    Choice 2:  He

    Choice 3:  She

If You Have Any Questions

If you have any questions, call us toll-free at 1-800-772-1213, or call your local Social Security office at [FO phone number from DOORS]. We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

[Field Office Address, City, ST, ZIP]

If you do call or visit an office, please bring this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly

Regional Commissioner

Enclosure:

SSA Pub. No. 05-10090

  

Exhibit 3

CONCURRENT CDR CESSATION NOTICE GROUP II EXCEPTION

SOCIAL SECURITY ADMINISTRATION

Retirement, Survivors and Disability Insurance

Supplemental Security Income

Notice of Disability Cessation

                                                                                                                      Date

                                                                                                                      123-00-6789 HA

Claimant Name

Address

City, State Zip

We are writing to let you know that we have made a decision on (1) Social Security and Supplemental Security Income (SSI) cases. After reviewing all of the information carefully, we have decided (2) no longer eligible for benefits.

Fill-ins:

  1. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  2. Choice 1:  you are

    Choice 2:  he is

    Choice 3:  she is

When (1) Payment Will Stop

Fill-ins:

  1. Choice 1:  Your

    Choice 2:  Disability claimant (possessive)

(1) no longer disabled as of (2) . If (3) getting payments, (4) will receive them for that month and the next 2 months, and (5) last payment will be for (6) .

Fill-ins:

  1. Choice 1:  You are

    Choice 2:  He is

    Choice 3:  She is

  2. Cessation month and year

  3. Choice 1:  you are

    Choice 2:  he is

    Choice 3:  she is

  4. Choice 1:  you

    Choice 2:  he

    Choice 3:  she

  5. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  6. Last month and year of entitlement/eligibility

The Decision On (1) Case

PDN Portion of Notice (2)

Fill-ins:

  1. Choice 1:  Your

    Choice 2:  Disability claimant (possessive)

  2. Personalized language

Information About (1) Medicare and Medicaid

Fill-ins:

  1. Choice 1:  Your

    Choice 2:  Disability claimant (possessive)

If (1) Medicare, (2) coverage will end the last day of (3) .

For information about any change in (4) Medicaid eligibility caused by this action, you should get in touch with (5) .

Fill-ins:

  1. Choice 1:  you have

    Choice 2:  he has

    Choice 3:  she has

  2. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  3. Last month and year of Medicare coverage

  4. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  5. Name of State Agency

If You Disagree With The Decision

If you disagree with this decision, you have the right to appeal. We will review your case and consider any new facts you have. A person who did not make the first decision will decide your case.

  • You have 60 days to ask for an appeal.

  • The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period.

  • You must have a good reason for waiting more than 60 days to ask for an appeal

  • You have to ask for an appeal in writing. We will ask you to sign a Form SSA-789-U4, called "Request for Reconsideration – Disability Cessation." Contact one of our offices if you want help.

Please read the enclosed pamphlet, "Your Right to Question the Decision to Stop Your Disability Benefits." It contains more information about the appeal.

Appeal In 10 Days To Keep Getting (1) Payment And Medicare

Fill-ins:

  1. Choice 1:  Your

    Choice 2:  Disability claimant (possessive)

You have only 10 days to ask us to continue (1) payments during your appeal.

  • The 10 days start the day after you get this letter.

  • You can ask us to keep paying (2) and (3) family.

  • Also, if you ask us to keep paying (4) and (5) covered by Medicare, (6) Medicare will continue.

  • If you lose your appeal, you might have to pay back some or all of this money, but you will not have to pay back Medicare.

Fill-ins:

  1. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  2. Choice 1:  you

    Choice 2:  him

    Choice 3:  her

  3. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

  4. Choice 1:  you

    Choice 2:  him

    Choice 3:  her

  5. Choice 1:  you are

    Choice 2:  he is

    Choice 3:  she is

  6. Choice 1:  your

    Choice 2:  his

    Choice 3:  her

How The Appeal Works

A Disability Hearing Officer will decide your appeal. We will call this person a DHO in the rest of our letter. The DHO will meet with you before making the decision on your appeal. The meeting works like this.

  • The DHO will write you about the time and place for the meeting.

  • You can look at (1) file before the meeting.

  • You can tell the DHO why you think (2) still disabled. You can give the DHO more facts. And you can bring people to say why (3) disabled.

  • You can have the DHO ask people to come to the meeting and bring important papers. You can question these people at the meeting.

  • You do not have to go to the meeting in person. If you do not want to go, you can give the DHO more facts you may have. The DHO will decide your case using these facts, and what is now in (4)