TN 14 (08-92)

DI 40510.150 Screening Folders to Determine Cessation Reason and Disabling Impairment

A. Policy

The DE will review the folder to determine whether the cessation was based on SGA and to verify the existence of a disabling impairment.

B. Procedure - verification of cessation reason

Review the most recent SSA-833-U3 in file to be certain that benefits were terminated because of SGA. (See DI 28084.015.)

1. Non-work cessation

If the cessation was based on medical reasons, i.e., current severity, medical improvement or an exception to medical improvement OTHER than SGA:

  1. Prepare an SSA-831-U3 per DI 40510.175 and forward the folder to the appropriate technician to complete an SSA-2795-U2 to post a denial to the RDD field of the MBR.

  2. Forward the folder to the typist for preparation and release of a disallowance notice to the individual per Exhibit 1, DI 40510.185.

  3. Instruct the typist to retain a copy of the notice in the claim folder for documentation.

2. Cessation based on SGA

If the cessation is based on SGA, proceed to C. below.

C. Procedure - verification of disabling impairment

To verify a disabling impairment, look for the most recent favorable medical determination in file, e.g., SSA-831-U3, SSA-833-U3 or SSA-899-U2. This may or may not technically be a CPD. Take the following steps to determine what action is needed to entitle an individual or to refer a case to the DDS.

1. Individual enrolls during IEP

  1. If an individual enrolls during the IEP, find him/her disabled for Premium-HI if the following conditions are met:

    • Favorable medical determination completed within past 2 years (for EPE /extended Medicare or medical CDR) AND

    • No past due scheduled CDR diary.

    • Individual alleges same impairment(s) that were present and documented at time of favorable medical determination.

  2. Prepare an SSA-831-U3 (DI 40510.175) and route the folder to the appropriate technician for enrollment action prior to notice preparation.

  3. Request the typist to send the individual a permanent award notice per Exhibit 2 in DI 40510.185.

  4. If there is a past due medical improvement expected (MIE) CDR diary, instruct the typist to send an interim award notice per Exhibit 3 in DI 40510.185, and forward case to the DDS under cover of an SSA-847-U3 for immediate CDR per DI 43535.025. Check blocks l.b and block 3 “Other”, and annotate the form “Section 6012 - Premium Medicare case.”

  5. If there is a past due medical improvement possible (MIP) or medical improvement not expected (MINE) diary or  more than 2 years since the last favorable medical determination was done, conduct new MFR per DI 40510.155.

2. Individual enrolls during GEP

If an individual enrolls during the GEP, follow DI 40510.150C.1. above. Coverage for GEP enrollments begins on July 1 of the current year.

Do not process a temporary award and interim notice for applications filed in January through March. Necessary processing should be completed before the first possible month of entitlement to Premium HI.

EXCEPTION: If there is no decision by June 1, process an interim award and send an interim notice to the individual.

3. Individual enrolls during SEP

If an individual enrolls during SEP, follow DI 40510.150C.1. above.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0440510150
DI 40510.150 - Screening Folders to Determine Cessation Reason and Disabling Impairment - 11