TN 13 (09-02)

SI 01150.112 Initial Claims with Period of Ineligibility and Disability Determination Needed

A. Introduction

The procedures in this section apply only to initial claims if:

  1. A transfer of resources occurred on or after 12/14/99;

  2. A period of ineligibility exists based on a transfer of resources;

  3. The individual does not meet one of the transfer exceptions listed in SI 01150.121 through SI 01150.125; and

  4. A disability determination by the disability determination services (DDS) is needed.

B. Procedure—Determining whether to send case to the DDS

Use this procedure for an initial claim that requires a medical decision from the DDS.

1. Determine whether undue hardship exists within 2 months of filing month

Follow the instructions in SI 01150.126 to determine whether the individual meets the requirements to receive SSI based on undue hardship for the month of filing or the following 2 months.

  1. Send the case to the DDS if the individual meets or is likely to meet the undue hardship requirements for any month of this 3-month period.

  2. Do not send the case to the DDS if the individual will not meet the undue hardship requirements for any month of the 3-month period.

NOTE: The determination of whether the individual is likely to meet the undue hardship requirements in the 3-month period is based on the claims representative's analysis of the facts in the specific case. These procedures are based on an understanding that an SSI applicant's financial situation (undue hardship) is subject to change during the life of the application.

2. Period of ineligibility ends within 2 months of filing month

Send the case to the DDS for a medical decision if the individual's period of ineligibility will end in the month of filing or in the following 2 months. This rule applies whether the individual appears to meet the undue hardship requirement or not.

Example: Mr. Smith files for SSI on 5/15/00 and it is determined that his resource transfer period of ineligibility will end in 7/00. Since the period of ineligibility ends within 2 months of the filing month, the field office sends the case to the DDS for a medical determination.

C. Procedure — Determining allowance or denial

1. Claim was not sent to the DDS

If the claim was not sent to the DDS because the period of ineligibility does not end and the individual does not meet the undue hardship requirements within the applicable 3-month period, process the claim as an N04 denial. See SI 01150.112D. for input instructions.

2. The DDS determines individual is not disabled

If the DDS determines that the individual is not disabled, process the medical denial. It is not necessary to adjudicate the transfer of resources issue. However, the file should be documented with the transfer information in the event that the individual files a reconsideration on the medical denial.

3. The DDS determines individual is disabled

Conduct your normal pre-effectuation review of the claim. Determine for each month starting with the month of filing whether the individual is eligible for SSI based on undue hardship. As needed, determine if the individual is eligible for any months because the period of ineligibility has ended.

a. Individual is eligible for at least 1 month

If the individual is eligible for at least 1 month of benefits, process the case as an allowance (assuming all other eligibility requirements are met).

Example: Mr. Wilson transferred a resource on 3/5/00 and filed for SSI on 4/20/00. Due to the resource transfer he will be subject to a period of ineligibility from 4/01/00-9/30/02. At the point that Mr. Wilson filed, it appeared to the CR that he would qualify for benefits based on undue hardship within the 3-month period, so the CR sent the case to the DDS. The DDS determined that Mr. Wilson is disabled and returned the case to the field office on 7/21/00.

The CR conducts the pre-effectuation review and determines that Mr. Wilson qualifies for payments based on undue hardship starting in 6/00. When processing the allowance, the CR inputs N04 for 4/00 and 5/00 because Mr. Wilson did not qualify for benefits based on undue hardship. The CR inputs C01 starting in 6/00. The CR documents the file that Mr. Wilson alleges undue hardship for future months and that it appears that he will meet the requirements based on an estimate of his total available funds expected in the future months. Then, the CR tickles the case using an RT diary per SI 01150.112D.3. to develop whether Mr. Wilson will continue to meet the requirements for payments based on undue hardship.

b. Individual is not eligible for an SSI payment

If the individual is not eligible for any SSI payment since the month of filing, process the case as a denial.

Example: Ms. Jones filed for SSI on 5/11/00. In 3/00 she gave away $15,000 cash to a relative so she is subject to a period of ineligibility. At the point Ms. Jones filed her claim, it appeared to the CR that she was likely to qualify for benefits based on undue hardship within the 3-month period, so the CR sent the case to DDS. The DDS determined that Ms. Jones is disabled and returned the case to the field office on 9/7/00. The CR conducts a pre-effectuation review on 9/15/00 and determines that, due to Ms. Jones' total available funds, she did not qualify for benefits based on undue hardship from the month of filing through 9/00. Therefore, the CR processes the claim as a denial and issues a manual notice to Ms. Jones on 9/15/00. On 11/3/00 Ms. Jones comes back to the office and requests benefits based on undue hardship as of 10/00. Since Ms. Jones is within the appeal period, the CR processes her request as a reconsideration of the 5/11/00 initial claim.

D. Procedure — Systems input

Use the following input procedures for claims processed on MSSICS or paper.

1. Payment status/denial code input

For input instructions, see SM 01005.440 for denial code field and SM 01005.476 for the payment status code field.

a. Allowance — Individual eligible for at least 1 month

  • Input C01 for any month(s) that the individual is eligible for an SSI payment due to undue hardship or because the period of ineligibility has ended.

  • Input N04 for any month(s) that the individual is ineligible for a payment due to the transfer of resources. (The case must be taken out of MSSICS in order to input N04 because MSSICS generates N04 only for months when an individual is over the resource limit.)

  • Suppress the automated notice by inputting the NP field (SM 01305.530). See SI 01150.150 for manual notice language.

b. Denial — Individual not eligible for an SSI payment

  • Input an N04 denial code as of the month of filing if the individual has a period of ineligibility due to a resource transfer and does not qualify for payments based on undue hardship. The case must be taken out of MSSICS to input N04.

  • Suppress the automated notice. See SI 01150.150 for manual notice language.

    NOTE: Cases in N04 payment status will terminate (T30/T31/T50/T51) using the existing termination rules. There is no special exception for resource transfer cases.

2. SSR Remarks

The SSR does not have data fields to record information about resource transfers. Therefore, it is necessary to record information about resource transfers in the SSR Remarks field. Input the following information (up to 120 characters) about the transfer, as appropriate:

  • Date of transfer;

  • Type of resource;

  • Uncompensated value;

  • Dates of period of ineligibility;

  • Months eligible based on undue hardship;

  • Months not eligible based on not qualifying for undue hardship;

  • Date when undue hardship recontact is needed (RT diary);

  • Any other information pertinent to the case.

NOTE: On MSSICS, use the CRMK screen (MSOM MSSICS 023.003 ). On non-MSSICS cases, use the R1-R5 fields (SM 01301.841)

3. Diary code inputs

a. RT diary for undue hardship recontact

If the individual is getting SSI payments based on undue hardship that will continue into the future, it is necessary to recontact the individual at regular intervals to redevelop undue hardship (See SI 01150.126F). Input the RT diary with the date that the individual must be recontacted to redevelop undue hardship.

Example: Ms. Green files an SSI claim on 6/5/00. She transferred a resource in 4/00 that resulted in a 12-month period of ineligibility which begins in 5/00 and ends in 4/01. The CR adjudicates the claim on 6/10/00 and finds that Ms. Green is eligible for SSI payments based on undue hardship beginning with the month of application (6/00 is an E02 month and the first payment is due for 7/00). Ms. Green alleges that without SSI payments she would face undue hardship for future months. The CR sets an RT diary for 11/01/00 so that Ms. Green can be recontacted to develop undue hardship for 7/00-11/00 and determine whether payments should continue after 11/00. After the 11/00 contact, the CR sets the RT diary for 4/01/01 which is the final month of the period of ineligibility.

b. MN diary for resource transfer

  • Input the diary code MN and the date of transfer whenever an individual has transferred a resource for less than fair market value. Use Form SSA-450S or SSA-1719B. if the MN diary is not propagated by MSSICS.

  • If the individual transferred a resource on 4/18/00, input "MN041800" in the diary (DA) field. This input is required for Medicaid whether the individual's SSI claim is awarded or denied. See SM 01005.213 for instructions on completion of the DA field.

  • Delete the MN diary by inputting "MN 00/00/00" in the DA field on an SSA-1719B. This diary can be deleted after the period of ineligibility ends.

NOTE: The MN diary is propagated automatically by MSSICS when the Property/Cash Given or Sold (RGIV) page is completed (See MSOM INTRANETSSI 013.034). To prevent MSSICS from setting an unnecessary MN diary, select "OTHER" as the "Method of Transfer" on the Property/Cash Given or Sold (RGIV) page when the individual disposes of an item of no value such as a junk car. Selecting "GIVEN AWAY" in that situation will generate an MN diary even though the disposed item has no value.

c. ME diary

  • Input the ME diary whenever an SSI claimant or beneficiary transfers a resource for less than FMV and will be subject to a period of ineligibility. This includes individuals who are subject to a period of ineligibility but qualify for SSI payments based on undue hardship (SI 01150.126). Do not input the ME diary if the individual has transferred a resource but is not subject to a period of ineligibility.

  • Input the ME diary in the DA field when completing the SSA-450S to clear the claim. The ME diary date is the last day of the final month of the period of ineligibility.

  • Check that the MN diary has been set when inputting the ME diary. Inputting the ME diary will cause a reject unless the MN diary is also set. Both MN and ME can be input on the same SSA-450S transaction. However, only 1 diary at a time can be input on SSA-1719B transactions.

  • Delete the ME diary by inputting “ME 00/00/00” in the DA field on an SSA-1719B. This diary can be deleted once the period of ineligibility has passed. The ME diary is informational only, so alerts will not be sent to the field office and it will not appear on any diary listings. And, it will not automatically drop off the SSR.

Example: Mr. Jones files for SSI on 12/15/01. He transferred a resource for less than fair market value on 10/21/01 which results in an 8-month period of ineligibility. His period of ineligibility begins in November, 2001 (the month after the transfer) and lasts through June, 2002. MSSICS has propagated the MN diary with the transfer date of 10/21/01, so the claims representative codes the DA field as follows: “ME 06/30/02.”</