TN 16 (04-06)

SI 00601.035 Adjudicating Title II When a Title XVI Application Is Filed

Citations:

20 CFR 416.120, 416.340 and 416.345

A. Introduction

When a claimant (or proper applicant on the claimant’s behalf) files a Title XVI application, he/she has also filed a Title II application. In these instances the claims adjudicator generally does not have enough information to adjudicate and effectuate Title II through the Modernized Claims System (MCS) and establish a Master Beneficiary Record (MBR). To ensure proper adjudication of the Title II application when the Title XVI application is filed, claims interviewers are now required to take a separate Title II application, with certain exceptions (see SI 00601.035B.2.), whenever a Title XVI application is taken (this includes uninsured Medicare beneficiaries who have some covered earnings).

When a separate Title II application is filed along with the Title XVI application, the appropriate claims adjudicator(s), as determined by local instructions, must process, adjudicate, and effectuate both applications. After fully developing all T2 issues, claims adjudicators may find that a disallowance is appropriate, e.g., 090 lack of insured status, or that res judicata may apply if the conditions in GN 04040.010C. are met.

When the claimant does not submit a separate T2 application and only a Title XVI application is filed, see SI 00601.035C.4. and SI 00601.035C.5. for instructions on adjudicating Title II. If one of the exceptions in SI 00601.035B.2. to taking a separate Title II application applies, the Title II claim is adjudicated by issuing the Title II adjudicative paragraph on the Title XVI award/denial notice (see “NOTE” in SI 00601.035B.3.b.). See SI 00601.035C.6. when adjudicating Title II to a denial.

B. Policy - Applications

1. Filed Title XVI Application is Also a Filed Title II Application

When the claimant (or proper applicant on the claimant’s behalf) files a valid Title XVI application, he or she has also filed a valid Title II application. In this situation, both the Title XVI and Title II applications must be processed, adjudicated and effectuated.

NOTE: An internet application (iClaim) submitted by a third party is not a valid application until we obtain the claimant’s signature, refer to GN 00204.055E.1 and GN 0204.027D for detail information.

If you discover that the Title II application that was filed when the Title XVI application was filed was never adjudicated, follow the instructions in GN 00204.027C. and GN 00204.027D.

See SI 00601.010D. for the scope of a Title XVI application, GN 00204.001 for the criteria of a valid application and GN 00204.007 for filing date policy.

2. Exceptions to Taking a Separate Title II Application

Do not take a separate Title II application when a Title XVI application is filed if:

  • the claimant already receives a Title II benefit and is not eligible for a higher Title II benefit (see GN 00204.004 for possible RIB spouse entitlement and GN 00204.022 to explore entitlement on another earnings record or to another class of benefits); or

  • the claimant is a child under age 16, has no covered earnings, which is substantiated by an earnings record (e.g., ICERS, SEQY) and is not eligible for any other Title II benefit, or

  • the claimant (or the proper applicant on the claimant’s behalf) alleges that he or she never worked in covered employment and the allegation is substantiated by an earnings record (e.g., online Informational/Certified Earnings Record System (ICERS), Summary Earnings Query (SEQY) and the claimant is not eligible for any other Title II benefit.

    NOTE: If the claimant does not meet one of the exceptions (e.g., he or she has some covered earnings), is not insured for Title II including MQGE and wants to file for Title II disability benefits, see GN 00204.009 for when to take an abbreviated application.

3. Adjudication of Title II

a. Title XVI Application and the Separate Title II Application Are Filed Simultaneously

If the Title XVI application and the separate Title II application are filed simultaneously, they must be processed, adjudicated and effectuated.

NOTE: Be sure to enter the windfall-offset code on the MCS BECF screen (See MSOM MCS 009.003). The entry of this code will prevent the release of the Title II retroactive payment until the Title XVI is paid. See GN 02610.005 for the windfall offset procedures and SI 02006.005B. for curtailing development in Title II offset situations.

b. Title XVI Application Filed - Exception Applies (No Separate Title II Application Required)

If the claimant meets one of the exceptions in SI 00601.035B.2., Title II is adjudicated when the Title XVI application is adjudicated by the issuance of the Title II adjudicative paragraph on the Title XVI award/denial notice. See SI 00601.035C.5. for the procedures including issuing the Title II adjudicative paragraph when the Title XVI application requires a disability determination.

See GN 00204.025B.2.c. for an explanation of the blanket Title II adjudicative paragraph.

NOTE: When the Title II adjudicative paragraph is included on the Title XVI award/denial notice, it constitutes a formal Title II determination with full appeal rights.

c. Title XVI Application Filed - No Exception Applies (Separate Title II Application Required)

If the claimant (or proper applicant on the claimant’s behalf) files for Title XVI benefits, but does not file a separate Title II application, follow the procedures in SI 00601.035C.4.

C. Procedure

1. Determine if the claimant is entitled to any class of Title II benefits or a higher Title II benefit than he/she is currently receiving.

a. Claimant (or Proper Applicant on the Claimant’s Behalf) Alleges Receiving Title II or Medicare

  • Obtain a MBR or Payment History Update System (PHUS) query to verify entitlement when the claimant is already receiving Title II or Medicare.

  • Explore entitlement to Title II benefits on other social security records.

    If the claimant is potentially entitled to another class of Title II benefit or a higher Title II benefit than he/she is currently receiving, take a separate Title II application. Follow the procedures in SI 00601.035C.2. or SI 00601.035C.3. as appropriate.

    If the claimant (or the proper applicant on the claimant’s behalf) is potentially entitled or is not entitled to Title II benefits and does not file a separate Title II application, follow the procedures in SI 00601.035C.4.

b. Title XVI Claimant or (Proper Applicant on the Claimant’s Behalf) Alleges No Title II or Medicare

  • Obtain a certified earnings record to determine Title II insured status being careful to consider the following in the determination: lag wages, recent self-employment income, military wages (including active or active reserve military service) and railroad earnings. Also, consider special insured status for disability before age 31. (See DI 10105.125 through DI 10105.170 and RS 00301.101 through RS 00301.160 for the policy on determining special insured status.

    NOTE: For claimants with non-covered earnings, consider possible entitlement to Title XVIII benefits under the MQGE provisions (see HI 00801.400 through HI 00801.440 for policy and procedures for MQGE).

  • Explore entitlement to Title II benefits on other SSNs, e.g., spouses, widows, or childhood disability benefits.

    If the claimant is potentially entitled to another class of Title II benefit or a higher Title II benefit than he/she is currently receiving, take a separate Title II application. Follow the procedures in SI 00601.035C.2. or SI 00601.035C.3. as appropriate.

    If the claimant (or proper applicant on the claimant’s behalf) is potentially entitled or is not entitled to Title II benefits and does not file a separate Title II application, follow the procedures in SI 00601.035C.4.

2. Title XVI Claimant (or Proper Applicant on the Claimant’s Behalf) Files For Title II - Title II Exception Does Not Apply

If none of the exceptions in SI 00601.035B.2. apply; take a separate Title II application when you take the Title XVI application. Process, adjudicate and effectuate the Title XVI and Title II applications.

NOTE: For teleclaims, attach the appropriate application cover notice to each application only if the claimant insists on signing the application with a wet signature. The application cover notices will closeout the Title II and Title XVI protective filings if the applications are not signed and returned within the protective filing closeout periods. If the Title XVI application is filed within the Title XVI protective filing period, a Title II application is also filed. However, if the Title II application is not filed timely, follow the procedures in SI 00601.035C.4. See SI 00601.040 for the Title XVI application cover notice and GN 00204.014 for the Title II application cover notice for pen and ink signatures. See GN 00201.015F.1.f. for applications signed via attestation.

3. Title XVI Claimant (or Proper Applicant on the Claimant’s Behalf) Files for Title II - Does Not Elect Full Title II Retroactivity

If the Title XVI claimant does not elect full Title II retroactivity, follow the filing for other benefit procedures in SI 00510.001, SI 00510.025 and SI 00510.030 when taking the Title XVI application. To insure proper adjudication of the Title II aspect of the Title XVI application, follow SI 00601.035A. If the claimant does not comply with the filing for other benefit procedures, you must deny/suspend, the Title XVI benefit.

4. Title XVI Claimant or (Proper Applicant on the Claimant’s Behalf) Does Not File a Separate Title II Application

a. Title XVI Claimant Potentially Entitled to Title II

If the Title XVI claimant (or proper applicant on the claimant’s behalf) does not file a separate Title II application, and the claimant does not meet any of the exceptions in SI 00601.035B.2., but is potentially entitled to Title II, (i.e., meets all factors of entitlement but we need additional information to properly adjudicate the Title II) take the Title XVI application and follow the filing for other benefit procedures in SI 00510.001 through SI 00510.030. If the claimant does not comply, deny the Title XVI application or suspend the Title XVI benefit. Adjudicate Title II by following the instructions in SI 00601.035C.6.

b. Title XVI Claimant Not Entitled to Title II

If the Title XVI claimant (or proper applicant on the claimant’s behalf) does not file a separate Title II application, and is not entitled to Title II, adjudicate the Title II application when the Title XVI application is filed by using the adjudicative paragraph on the Title XVI award/denial notice.

5. Title XVI Claimant Meets One of the Exceptions in SI 00601.035B.2.

If the claimant meets one of the exceptions in SI 00601.035B.2., do not solicit a separate T2 application. Adjudicate Title II when the Title XVI application is adjudicated by issuing the blanket Title II adjudicative paragraph on the Title XVI award/denial notice as follows:

a. Modernized Supplemental Security Income Claims System (MSSICS) Applications

Document the MSSICS Report of Contact (DROC) screen that the claimant is not entitled to any class of Title II benefits or a higher Title benefit than he/she is currently receiving, or Medicare.

Answer, “No”, to the potential entitlement to Social Security benefits question on the MSSICS, Social Security (BSSA) screen. The Title II adjudicative paragraph will be automatically included in the Title XVI award/denial notice. On November 17, 2007, four additional MSSICS screens were released to document the development of Title II entitlement. For initial claims events that are opened on or after November 17, 2007, the information from the new screens, BSRD, BSSW, BSCF, and/or BSCM, will be used to build a reliable closeout indicator to the SSR. Open initial claims events prior to November 17, 2007 will still have a BSSA screen and the information on that screen will be used to build the closeout indicator on the SSR.

b. Manual Input Process

Circle the CL field on the SSA-450-SI. When the CL field is input into the system, the adjudicative paragraph is automatically included in the Title XVI award/denial notice.

c. Disability Application

Annotate the remarks section of Completing the Paper Form SSA-3367–F5 (Disability Report—Field Office (see DI 11005.045) to request that the Disability Determination Services (DDS) issue the Title II blanket adjudicative paragraph on the disability denial notice if it is determined that the claimant is not disabled.

If the DDS determines that the claimant is disabled and a manual input is required, follow the instructions in SI 00601.035C.5. second bullet for issuing the Title II adjudicative paragraph on the Title XVI award/denial notice.

d. Manual Notice

If a manual award/denial notice must be issued because of a systems limitation, include paragraph 1598 (see NL 00804.245) to adjudicate Title II. Document the supplemental security income record (SSR) Remarks field that the Title II adjudicative paragraph was issued on the manual Title II award/denial notice. Also include the date the notice was issued.

6. Adjudicating Title II to a Denial

When the claimant is potentially entitled to Title II and does not file a separate Title II application, adjudicate and effectuate Title II by preparing a denial using code 64 via EC processing or in MACADE. See MSOM MCS 009.003 for EC processing and POMS sections SM 00380.040 and SM 00805.400 for MACADE processing. Annotate the MBR with a SP MSG to explain the reason for denial such as: “064 failure to establish other requirements for entitlement.”

When MCS is used, the NOT3 screen (see MSOM MCS 009.010) should be coded giving the reason for the denial. If MACADE is used, the FO must input the denial and prepare the denial notice on DOCS, specifying the reason for the denial (i.e., failure to provide necessary information). The resulting MBR will be evidence that the Title II application is no longer open.

If the claimant is still receiving SSI benefits, and entitled or potentially entitled to Title II benefits, follow the procedures in SI 00510.001 through SI 00510.030 (Filing for Other Benefits) to suspend the SSI benefits.

If the claimant subsequently contacts SSA to complete the supplemental application, treat the supplemental application as an implied request for reconsideration. If the date of the contact is after the appeals period has expired, determine if there is good cause for late filing and process the reconsideration request accordingly.

D. References


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0500601035
SI 00601.035 - Adjudicating Title II When a Title XVI Application Is Filed - 07/10/2014
Batch run: 07/10/2014
Rev:07/10/2014