DI 52170.010 Form SSA-2455 (Offset Worksheet-Disability Insurance Benefits)
A. Purpose of the Form SSA-2455
Use the SSA-2455 to compute the amount of workers’ compensation/public disability benefits (WC/PDB) offset. You may use the e2455+, a new tool for calculating amounts payable after WC/PDB offset, instead of the paper Form SSA-2455. The e2455+ can propagate offset rates into OREO (see DI 52165.020).
B. When to complete a paper SSA-2455
Complete a paper SSA-2455 only when you cannot use an Interactive Computations Facility (ICF) program or e2455+ due to systems limitations. For more information, see DI 52145.015 – Retention of Workers’ Compensation/Public Disability Benefits (WC/PDB) Proofs.
C. Form SSA-2455 Exhibit
Click here for an example.
D. Disposition of the SSA-2455
If the SSA-2455 cannot be stored or recorded in the Modernized Claims System (MCS), Modernized SSI Claims System (MSSICS), or the ICF, fax the form into the Non-Disability Repository for Evidentiary Documents (NDRED) or the electronic disability (eDIB) folder, as appropriate.
NOTE: If processing center (PC) action is required, the FO will also fax the form to the PC’s paperless fax number.
E. Completing the SSA-2455
Prepare a separate SSA-2455 for each month there is a change in the following:
EXCEPTION: Use Form SSA-2454 in DI 52170.020 for WC/PDB rate changes occurring after a triennial redetermination.
Enter the worker’s Social Security number on each SSA-2455.
1. Part 1 – Offset data
a. Period covered by this worksheet
Enter the period of time for which the computation is applicable, (e.g., 06/1995 – 05/1997, 07/1996 only, 06/1998 on).
b. Month of entitlement
Enter the DIB month of entitlement (MOET).
c. First month of offset
Enter the first month offset was considered or imposed, whichever is earlier. For more information, see DI 52150.020 – Workers’ Compensation/Public Disability Benefits (WC/PDB) Offset Effective Date (OED).
d. Family benefit computation
Enter each beneficiary's benefit amount in the first possible month of offset. Add all the benefit amounts and enter the sum for the TFB. For more information, see DI 52150.005 – Total Family Benefits (TFB).
e. 100 percent Average Current Earnings (ACE)
Enter the 100 percent ACE rounded down to the nearest dollar.Use unindexed covered earnings. Check the appropriate block to identify the highest ACE. Show the year and earnings used if a High-1 ACE is used. For information on ACE, see DI 52150.010 – Average Current Earnings (ACE).
NOTE: The ACE shown on the MCS Remarks screen is the 80 percent ACE.
f. 80 percent ACE
Multiply the 100 percent ACE by 0.8.
2. Part 2 – Offset computation
This part of the form establishes a base rate for all beneficiaries. The total Social Security disability benefits payable in the first month of offset plus the monthly WC/PDB cannot exceed the applicable limit (the higher of the 80 percent ACE or TFB (total family benefits).
Subtract the monthly WC/PDB from the applicable limit to find the total benefits payable to the family in the first possible month of offset.
Pay the number holder first and any excess is distributed among the auxiliaries.
a. Applicable limit
Enter the higher of the TFB or the 80 percent ACE. For determining the applicable limit, see DI 52150.015.
b. Monthly WC/PDB
Enter the monthly WC/PDB rate. Round the monthly amount down to the next lower dime. Indicate if the amount has been verified (by checking the verified block). (For example, $578.58 would be rounded down to $578.50.) If not verified, obtain verification. See DI 52150.035 - Determining the WC/PDB Amount.
c. Total benefits payable after offset
Subtract the monthly WC/PDB from the applicable limit and enter the amount. Do not enter an amount less than zero.
If this amount is equal to or higher than the number holder's monthly benefit amount (MBA), the number holder receives the full MBA.
If this amount is higher than the TFB, do not offset and do not complete the rest of the form. Annotate the MBR with the OFT code OP (Offset Postponed).
If this amount is less than the number holder's MBA, this is the amount payable to the number holder in the first possible month of offset. (i.e., total offset applies to the auxiliaries.)
d. Worker’s MBA
Enter the PIA, unless reduced for age. If so, enter the reduced DIB.
e. Amount payable to auxiliaries
Subtract the number holder’s MBA (Part 2 D.) from the total benefits after offset (Part 2 C.) and enter the amount.
f. Number of auxiliaries
Enter the number of auxiliaries entitled for the months shown in the period covered by the worksheet, including delayed auxiliaries and any auxiliary whose payment is marked “Do Not Certify”. (This will protect the benefits payable to auxiliaries not yet certified for payment.) NOTE: Recalculate the offset whenever there is a change in the number of auxiliaries.
g. Amount payable to each auxiliary
Divide the amount payable to auxiliaries (Part 2 E.) by the number of auxiliaries (Part 2 F.), if the auxiliaries' benefit amounts before offset are equal. See DI 52170.025 - Rounding Rules for Offset Computations.
Distribute this amount proportionately if the auxiliaries' benefit amounts before offset (i.e., amounts used in the TFB) are not equal, (e.g., a reduced or dually-entitled spouse and 3 children or an HB6 or an HB9 is involved).
Apply the following formula to distribute the amounts payable after offset:
Benefits payable to all auxiliaries after offset (Part 2 E.);
Multiplied by the auxiliary benefits before offset; then
Divided by the total of the auxiliary amounts used to compute TFB.
1. Total benefits payable to all auxiliaries after offset = $150.00
2. HB MBA = $120.00
HC1 MBA = $160.00
3. Total Auxiliary benefits used to compute TFB = $280.00
HB $150.00 X $120.00 = $64.20 (rounded down - MOE after 6/82)
HC1 $150.00 X $160.00 = $85.70
3. Part 3 – Increase not subject to offset
a. Claims symbols
Enter the auxiliaries symbols (BICs).
b. Protected increases
Enter the month and year of each increase.
Enter each increase that is effective after the first possible month of offset.
Show the number holder's increase under “HA”.
If the auxiliaries' increases are equal, use one column to show the auxiliary rates. For example, if the BICs on record are HA, C1, C2 and C3, label one column HA and label one column C1, C2, C3. NOTE: Do not combine the auxiliary amounts.
Use the remaining columns if the auxiliaries' increases are not equal.
NOTE: Protected increases are increases that are not subject to offset by a recomputation or SSA cost-of-living increase. See DI 52150.055 to determine protected increases.
c. Amount payable
Enter the amount payable after offset to the number holder (from Part 2 C. or 2 D.) and to each auxiliary (from Part 2 G.).
d. Total amounts payable
Add each column.
e. Signature and date
Sign and date the form. Then, scan or fax into the claims folder.
4. Completing the back of the SSA-2455
Use the reverse side of the SSA-2455 to manually prorate a lump sum settlement and to document calculations involving mid-month WC/PDB rate changes. See manual proration instructions for SSA-2455 in DI 52170.030.