BASIC (09-08)

DI 52170.020 Form SSA-2454 (Offset Worksheet – Triennial Redetermination Previously Applied)

A. Purpose of the Form SSA-2454

Use the Form SSA-2454 to compute the amounts payable to the number holder and auxiliaries when the WC/PDB rate changes after a redetermination increase. You may use the e2455+ a new tool for calculating amounts payable after WC/PDB offset, instead of the paper Form SSA-2454. The e2455+ can propagate offset rates into OREO (see DI 52165.020).

B. When to complete a paper SSA-2454

Complete a paper SSA-2454 only when you cannot use an Interactive Computation Facility (ICF) program or e2455+ due to systems limitations.

C. SSA-2454 versus SSA-2455

If the average current earnings (ACE) is the applicable limit, an overpayment may result if a SSA-2455 is used in lieu of the SSA-2454. In some situations, a redetermination may have yielded an increase but a subsequent event (such as entitlement of an auxiliary), may void that increase. If this occurs, use a SSA-2455 to recompute offset when there is a change in the amount of WC/PDB. If a SSA-2454 is used in these situations, incorrect benefit amounts will result.

D. Form SSA-2454 exhibit


E. Disposition of the SSA-2454

If the SSA-2454 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.

F. Completing the SSA-2454

Completing this form requires jumping from Part 1 to Part 2, and then back to Part 1. Enter the worker’s Social Security number.

1. Part 1 – Offset calculation

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. Family benefit computation

Enter the total family benefit (TFB) that was effective in the first possible month of offset.

c. Redetermined Average Current Earnings (ACE)

Enter the redetermined 100 percent average current earnings (ACE) rounded down to the nearest dollar. Do not use an old ACE.

d. 80 percent of redetermined ACE

Enter 80 percent of the redetermined ACE.

e. Applicable limit

Enter the higher of TFB or 80 percent redetermined ACE.

f. Monthly WC/PDB

Enter the new amount of WC/PDB.

g. Total benefits payable after offset

  • Subtract the new WC/PDB rate (line F) from the applicable limit (line E) and enter the amount. Do not enter an amount less than zero.

  • If this amount is equal to or higher than the insured number holder's monthly benefit amount (MBA), the insured number holder receives their full MBA.

  • If this amount is higher than the TFB, do not offset and do not complete the rest of form.

h. Worker's current MBA

Enter the insured number holder's current MBA in the month of the last triennial redetermination with the month of the change in the WC/PDB rate.

i. Go to Part 2 (lines I and J are completed later).

2. Part 2 – Increases not subject to offset

a. Claims symbols

Enter the auxiliaries symbols (BICs) in the columns.

b. Protected increases

Enter all HA and auxiliary increases effective after the month offset was first imposed. NOTE: The amount entered in the block for the redetermination increase is the difference between the amount payable in the month before the month of the redetermination (i.e., after all statutory and recomputation increases) and the amount payable after the redetermination.

NOTE: The last increase entered on line B must be the redetermination increase. Do not show increases effective after the redetermination here.


HA is in total offset 06/1996 ($0.00 payable).

HA $33.10 payable - Due to 12/1998 statutory (COLA) increase.

36.10 payable - Due to 01/1999 redetermination increase.

3.00 difference - Enter this amount on the line 2B, along with the COLA of 33.10

Enter the total increase of 36.10 in Part 1, line I.

c. Go back to Part 1 Line I.

d. Sum of all protected increases in Part 2

Enter in line I only those protected increases shown in Part 2 (line B) including protected increases for HA and all auxiliaries (made prior to, and including the latest redetermination).

e. Unprotected balance payable

Subtract line I (protected increases) from line G (total benefits payable after offset) and enter this amount.

f. Return to Part 2 line C.

g. Total (HA increases only)

Enter the total of all HA increases (statutory and redetermined).

h. Total of Part 1 Line J and Part 2 – Line C

Add the total of unprotected balance payable (1J) and HA increases (2C) and enter that amount in Part 2, line D.

i. Amount payable to HA

Part 1 line H is the number holder’s PIA. If the amount in line H equals or exceeds Part 2 line D, pay amount in 2D to HA, otherwise pay amount in 1H to HA (the lower of 1H or 2D will be the HA payable). This amount is the sum computed before protected increases occurring after the redet. If there were protected increases after the last redet, add the increases after the redet and before the change in WC/PDB. This brings the rate up to the rate payable at that point.

j. Amount payable to the auxiliary

Subtract line E from line D and enter the difference in line 2F.

k. Divide by number of auxiliaries

  • Enter the number of auxiliaries in the first column.

  • Divide line F by the number of auxiliaries.

  • Enter this amount under the Part 2 line G columns for all auxiliaries (whose BICs are listed).

l. Total to auxiliaries

  • Add all protected increases in Part 2, line B and Part 2, line G for each auxiliary. Do not include HA increases.

  • Enter this total for each auxiliary BIC is listed. This sum is the amount before protected increases occurring after the redet. If there were protected increases after the last redet, add the increases after the redet and before the change in WC/PDB. This brings the rate up to the rate payable at that point.

m. Signature and date

Sign and date the form. Then, scan or fax into the claims folder.

n. Completing the back of the SSA-2454

Use the back of the SSA-2454 to manually prorate lump sum settlement awards or other calculations (e.g., WC/PDB mid-month adjustments, etc.).

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DI 52170.020 - Form SSA-2454 (Offset Worksheet - Triennial Redetermination Previously Applied) - 11/30/2015
Batch run: 11/30/2015