NL 00710.010 Guide Paragraphs

A. Opening Paragraphs

 

1000—REFERENCE TO LETTER OR TELEPHONE INQUIRY—FIRST RESPONSE

1000A—I am responding to a telephone call of       by a member of your staff about       .

1000B—This refers to your letter/inquiry/telephone call of       to       about       .

1000D—I am responding to a telephone call by       on your behalf regarding       .

1000E—I am responding to the letter written on your behelf by       about       .

1000F—We recently received an inquiry on your behalf from       .

1000G—Thank you for informing us of       , (Do not use concerning notification of death.)

 

1001—REFERENCE TO LETTER OR TELEPHONE INQUIRY—SUBSEQUENT RESPONSE.

1001A—This supplements previous correspondence about       .

1001B—This is in further response to your letter/inquiry about       .

1001C—This refers to your letter/inquiry/telephone call of       and supplements previous correspondence about       .

1001D—This supplements previous correspondence from       about       .

 

1002—REPLY TO INQUIRY FROM OUTGOING MEMBER OF CONGRESS (REPLY TO NEW MEMBER)

We are writing you in response to a request from the Honorable       about       . We could not fully answer his/her letter at the time he/she inquired because we did not have all the necessary information.

 

1003—INQUIRIES ADDRESSED TO THE PRESIDENT

I am responding to your letter to the President.

 

1004—ACKNOWLEDGEMENT HAS ALREADY BEEN SENT FOR THE PRESIDENT

1004A—I am responding further to your letter to the President.

1004B—Your recent letter to the President has been referred to us for further reply.

 

1005—ESPECIALLY INTERESTING OR COMPLIMENTARY LETTER DIRECTED TO THE PRESIDENT (THIS WORDING WILL RARELY BE USED.)

The President has asked us to thank you for your recent letter and to reply to it since it relates to a social security matter.

B. Interim Response Paragraphs

 

1050—ACKNOWLEDGMENTS

1050A—We are giving your letter/inquiry our attention and will soon be in touch with you.

1050B—In response to your letter/inquiry we are looking into the status of M       's claim. We will contact you again when the necessary information is available.

 

1051—CASE IN DO—REPORT RECEIVED

Your/M       's claim for disability benefits is presently in the       Social Security office. The people there tell us that        .

1052—CASE RECENTLY SENT TO DO

Your/M       's records were recently sent to the       Social Security Office because (explain why).

 

1053—CASE BEING SENT TO DO FOR PERSONAL EXPLANATION OF DENIAL DECISION

Your/M       's application for disability insurance benefits was denied because it was determined that the evidence did not show you/him/ her (See 1104). Because of the information furnished with/in your letter, I have ask the people in the       Social Security Office to give you/him/her a further explanation of the decision. Our representatives will help you/him/her file for a reconsideration if you wish/he wishes/shes wishes to do so. They will also answer any questions you/he/she may have about your/his/her claim.

 

1054—CASE SENT OR BEING SENT TO DO AND DDS—RECONSIDERATION REQUESTED

Since you/M       have/has requested reconsideration of the claim, your/his/her records have been sent/are being sent to the        Social Security Office. You/He/She will have an opportunity to present your/his/her case and will be given assistance in obtaining additional evidence. When this is completed, your/his/her claim will be re-evaluated by the       State agency, which works with us in making disability determinations.

 

1055—DENIED CASE BEING RE-EVALUATED— BEING SENT TO DO AND DDS

Our disability staff has reviewed your/M       's claim, and I am now sending it to the       Social Security office to obtain additional information. When the information is obtained that office will send the claim for re-evaluation to the       State agency, which works with us in making disability determinations.

 

1056—CASE BEING RETURNED TO DDS THROUGH DO—ADDITIONAL NON-MEDICAL DEVELOPMENT REQUIRED

The people at the       Social Security Office have been requested to obtain additional information concerning your/M         's work activity/work background. This evidence is needed to evaluate/ re-evaluate your/his/her disability claim. The information will then be sent to the         State agency for further consideration. This will cause some delay, but every effort will be made to complete this work as quickly as possible.

 

1057—CASE IN DDS—REPORT RECEIVED

Your/M       's claim for disability benefits is in the       State agency, which works with us in making disability determinations. That agency tells us       .

 

1058—CASE RECENTLY SENT TO DDS

Your/M       's claim was recently sent to the       State agency, which works with us in making disability determinations. (Explain why.)

 

1059—CASE IN DDS FOR RECONSIDERATION— REPORT RECEIVED

Your/M       claim and related records have been sent for reconsideration to the       State agency, which works with us in making disability determinations. That agency tells us       .

 

1060—REQUEST FOR RECONSIDERATION—CASE IN DDS1

As you/M       requested, your/his/her disability claim is now being re-evaluated by the       State agency which works with us in making disability determinations. That agency tells us       .

 

1061—CASE BEING SENT TO DDS FOR RE-EVALUATION

Because of the information furnished with/in your letter, we are asking the       State agency, which works with us in making disability determinations, to further consider the claim.

 

1062—CASE BEING SENT TO DDS FOR ADDITIONAL INFORMATION AND RE-EVALUATION1

Our disability staff has reviewed your/M       's claim and we have asked the       State agency, which works with us in making disability determinations, to obtain additional information and to re-evaluate the claim as quickly as possible.

 

1063—CASE RETURNED TO DDS FOR FURTHER CONSIDERATION

The       State agency has evaluated/re-evaluated your/M        's claim and found that certain aspects need further study before a decision is made. The State agency will complete its determination as quickly as possible.

 

1064—CASE RETURNED TO DDS FOR ADDITIONAL MEDICAL DEVELOPMENT

The       State agency evaluated/reevaluated your/M       's claim and found that additional medical evidence should be obtained before a decision is made. We are asking the agency to get this evidence and further consider the case. When this information is received action on the claim will be completed as quickly as possible.

C. Decision Paragraphs

 

1100—ALLOWANCE OF DIB

1100A—A monthly disability benefit of $       has been approved for you/M       beginning       , and you/M       should receive a check shortly. Your/M       's period of disability began       and your/M       's required waiting period of 5 consecutive calendar months ended       . Your /His/Her first month of entitlement is therefore       , the first month after the waiting period.

1100B—As a result of the reconsideration/Administrative Law Judge's/ Appeals Council's decision, your/M       's claim for disability insurance benefits has been approved. You/He/She is entitled to monthly benefits of $       beginning       . Checks for the payments due are being/have been sent to you/him/her. In the future, you /M       will receive benefits on a regular monthly basis.

1100C—Your/M       's wife/husband and children/daughter/ son have also been awarded monthly benefits of $       each, effective       .

1100D—However, the family will receive total benefits of $       monthly because this is the maximum amount payable on your/M       's earnings record.

1100E—No disability payments can be made for any part of the required 5-calendar month waiting period. Thus, benefits cannot be paid to you/M       for any month before       , even though your/his/ her period of disability began on       .

 

1100.2—ALLOWANCE—DIB—PERIOD OF DISABILITY BEGINS LATER THAN ALLEGED ONSET DUE TO DATE EARNINGS REQUIREMENT FIRST MET

An award of monthly disability benefits has been approved for you/M        in the amount of $       effective       .

The law provides that an individual can be entitled to disability benefits only if he/she meets both an earnings and a disability requirement. A person disabled (1) or (2), or (3). The evidence show that you/M        first met both requirements on       . Therefore, this is the earliest date your/M       's period of disability can begin. The law provides for a 5-calendar-month waiting period before disability payments can start.

(1) before age 24 must have credit for at least 6 calendar quarters (1 1/2 years) of work under social security during the 3-year period ending with a quarter in which the disability begins.

(2) at ages 24 through 30 must have credit for work under social security in at least one-half of the calendar quarters beginning with the quarter after age 21 and ending with the quarter in which the disability begins.

(3) at age 31 or later must meet two covered work requirements. First, he/ she needs 20 calendar quarters (5 years) of work under social security during a 40-quarter period (10 years) ending in or after the quarter the disability begins. Second, he/she also needs credit for one calendar quarter of work for each year after 1950 (or after reaching age 21, if that is later) up to the year the disability begins. In the second instance, the credits may have been earned at any time.

 

1103—CLOSED PERIOD

You/M       are/is entitled to disability payments beginning       and ending       based on a determination that you /he/she were/was disabled from       through       .

The law provides for a 5-calendar-month waiting period before disability payments can begin and continues the period of disability for 2 months after the month in which a person's condition has improved to the extent that it no longer prevents him/her from working.

 

1104—INITIAL DENIAL—DISABILITY REQUIREMENTS NOT MET

Your M       's application for disability benefits was denied because it was determined that the evidence did not show you/him/her (See (1) through (6) below). The evidence regarding your/his/her condition was evaluated by the State agency, which assists us in making disability determinations, and was reviewed by our disability staff.2

  1. to be disabled.

  2. to be disabled any time you/he/she met the earnings requirement of the law.

  3. to have a disabling condition which must be expected to end in death or which has lasted or can be expected to last for a continuous period of at least 12 months.

  4. to have a medical condition so severe enough to keep you/him/her from doing any substantial gainful work for which you/he/she are/is qualified.

  5. to be disabled within the 7-year period specified by law for widows/ widowers/surviving divorced spouses.

  6. to be disabled since before age 22.

     

1104.1—INITIAL DENIAL—ENGAGED IN SGA (TO BE USED IN CONJUNCTION WITH PARAGRAPH 1162)

Your M       's application for disability was denied because it was determined that the work you/he/she are/is doing demonstrates you/he/ she are/is able to do substantial gainful work despite any impairment you/ he/she may have.

 

1105—INITIAL DENIAL—EARNINGS REQUIREMENT NOT MET

Your M       's application for disability benefits was/has been denied because you/he/she do/does not meet the earnings requirement of the law on the date you/he/she stated you/he/she became disabled.

 

1106—RECONSIDERATION DENIAL— DISABILITY REQUIREMENTS NOT MET

1106A—Your M       's application for disability benefits was denied because it was determined that the evidence did not show you/him/ her (See (1)-(6) below). You/He/She requested reconsideration of your/his/her claim. The evidence regarding your/his/her condition was re-evaluated by the State agency, which works with us in making disability determinations, and it was reviewed by our disability staff.2 They conclude that the previous decision was correct.

  1. to be disabled.

  2. to be disabled any time you/he/she met the earnings requirement of the law

  3. to have a disabling condition which can be expected to end in death or which has lasted or can be expected to last for a continuous period of at least 12 months

  4. to have a medical condition so severe enough to keep you/him/her from doing any substantial gainful work for which you/he/she are/is qualified.

  5. to be disabled within the 7-year period specified by law for widows/ widowers/surviving divorced spouses.

  6. to be disabled since before age 22.

1106B—The evidence regarding your/M       's condition has been re-evaluated by the State agency which works with us in making disability determinations, and reviewed by our disability staff.2 They conclude that the previous decision was correct and that the evidence did not show you/him /her (See (1)-(6) above.

 

1106C—RECONSIDERATION DENIAL— ENGAGED IN SGA

The evidence regarding your/M       's claim has been re-evaluated. It was determined that the work you/he/she is doing shows you /he/she are/is able to engage in substantial gainful work despite any impairment you/he/she may have.

 

1107—RECONSIDERATION DENIAL— EARNINGS REQUIREMENT NOT MET

1107A—Your/M       's application for disability insurance benefits was denied because it was determined that you/he/she did not meet the earnings requirement of the law. You/he/she requested reconsideration of the claim. Your/his/her case was/has been carefully reviewed and it was/has been determined that the previous decision was correct.

1107B—Your M       's application for disability insurance benefits was denied because it was determined that you/he/she did not meet the earnings requirement of the law. We have carefully reviewed your/his/her entire case and have determined that the previous decision was correct.

 

1108—DENIAL UPHELD BY ALJ—NO SUBSEQUENT APPEAL ACTION TAKEN

Your/M       filed a claim for disability benefits on       which was denied initially and on reconsideration because it was determined that you/he/she (1) or (2) or (3) . The claim was also denied by an Administrative Law Judge of the Office of Disability Adjudication and Review, and that decision is the last administrative action on the claim.

  1. were not disabled.

  2. were not disabled at any time you/he/she met the earnings requirement of the law.

  3. were not disabled during the 7-year period specified by law for widows/ widowers/surviving divorced spouses.

     

1109—DENIAL OF SUBSEQUENT APPLICATION

Another application for disability insurance benefits was filed by you/M       in       . This claim was/has been denied because you/he/she do/does not meet the earnings requirement of the law any time after the date of your/his/her previously denied application. No decision was/has been made as to whether you/M       are/is now disabled, since an impairment which occurs or becomes disabling after the earnings requirement is last met may not qualify an individual for disability benefits. When your/M       's latest application was received the previous decision was carefully reviewed, and no basis could be found for changing it. (Delete last sentence if previous decision was upheld by an administrative law judge.)

 

1110—CESSATION—INITIAL

You/M       were/was found to be disabled within the meaning of the law beginning  (Date)  . Your/His/Her records, together with the additional information obtained, were evaluated by the State agency which assists us in making disability determinations. The claim was reviewed by our disability staff.3 They determined the evidence showed (3), or (4) or (5). Therefore, your/his/her disability benefits ended       .

 

  1. Certain cases are reexamined from time to time to insure that the individual's condition is still disabling. A special examination was arranged to determine whether you/he/she continued to be disabled as that term is defined in the law.

  2. Since information was received which indicated that you/he/she were /was working, an investigation was made.

  3. you/he/she are/is able to do substantial gainful work.

  4. the work you/he/she had performed demonstrated your/his/her ability to do substantial gainful work.

  5. you/he/she were/was not disabled within the meaning of the law.

     

1111—CESSATION—BENEFITS PREVIOUSLY SUSPENDED PENDING COMPLETION OF CDR

Your/M      's benefits were suspended pending clarification of your/his/her work activity. Additional information was obtained and it has been determined that your/his/her period of disability ended       because you/he/she did not meet the disability requirements of the law.

 

1112—CESSATION—RECONSIDERATION

1112A—Your/M      's disability benefits ended       because  (1) or (2) . Since you/he/she requested a reconsideration of this decision, the evidence regarding your/his/her condition was re-evaluated by the       State agency and reviewed by our disability staff.3 They have determined that the decision to end your/his/her disability benefit was correct.

(1) medical evidence showed that you/he/she are/is able to resume some type of substantial gainful work.

(2) you/he/she were/was not disabled within the meaning of the law.

1112B—The evidence regarding your/M       's disability has been re-evaluated by the State agency which works with us in making disability determinations, and reviewed by our disability staff.3 They concluded that the decision to terminate your/his/her benefits was correct.

 

1113—CESSATION AFFIRMED UPON RECONSIDERATION—NEW APPLICATION DENIED

The State agency and our disability staff4 reviewed your/M       's claim and found the decision to stop your/his/her disability benefits to be correct. They have also denied your/his/her recent application for disability benefits.

D. Requirements of Law and Regulations Paragraphs

 

1150—EARNINGS REQUIREMENT—GENERAL AND SPECIFIC

1150A—General

The law requires that a disabled person must have a specified amount of social security credits during a particular period of time. A person disabled before age 24 must have credit for at least 6 calendar quarters (1 1/2 years) of work under social security during the 3-year period ending with the quarter in which the disability begins.

 

A person disabled at ages 24 through 30 must have credit for work under social security in at least one half of the calendar quarters beginning with the quarter after age 21 and ending with the quarter in which the disability begins.

 

A person disabled at age 31 or later must meet two covered work requirements:

(1) he/she needs 20 calendar quarters (5 years) of work under social security during the 10-year period ending with the quarter disability begins.

(2) he/she also needs credit for 1 calendar quarter of work for each year after 1950 (or after reaching age 21, if that is later) up to the year the disability begins.

In the second instance, the credits may have been earned at any time.

1150B—Specific

One of the requirements of the law is that a person disabled  (1) or (2) or (3).

(1) before age 24 must have credit for at least 6 calendar quarters (1 1/2 years) of work under social security during the 3 year period ending with the quarter in which the disability begins.

(2) at ages 24 through 30 must have credit for work under social security in at least half of the calendar quarters beginning with the quarter after age 21 and ending with the quarter in which the disability begins.

(3) at age 31 or later must meet two covered work requirements:

(a)

needs 20 calendar quarters (5 years) of work under social security during a 40-quarter period (10 years) ending in or after the quarter the disability begins.

(b)

he/she also needs credit for 1 calendar quarter of work for each year after 1950 (or after reaching age 21, if that is later) up to the year disability begins.

In the second instance, the credits may have been earned at any time.

 

1151—DIB AND FREEZE—DISABILITY REQUIREMENTS

To be considered disabled for social security purposes, a person must be unable to do any substantial gainful work because of a medical condition which has lasted or can be expected to last for a continuous period of at least 12 months or must be expected to end in death. His/Her impairment must be severe enough to prevent him/her from working not only in his/her usual occupation but in any other substantial gainful work. His/Her age, education, remaining functional capacity, training, and work experience are considered in determining how his/her impairment affects his/her ability to work.

 

1152—DIB AND FREEZE—DISABILITY AND EARNINGS REQUIREMENTS

To be considered disabled for social security purposes a person must be unable to do any substantial gainful work because of a medical condition which has lasted or can be expected to last for a continuous period of at least 12 months or must be expected to end in death. His/Her impairment must be so severe as to prevent him/her from working not only in his/her usual occupation but in any other substantial gainful work considering his/her age, education, remaining functional capacity, training, and work experience. In addition, the disability must exist at a time when the earnings requirement is met.

To meet the earnings requirement, a person disabled  (1) or (2) or (3).

Your/M       's social security record shows that you/he/she last met this earnings requirement on       . To qualify for disability benefits, your/his/her disability must have begun on or before this date. A medical condition which may have occurred or become disabling after the earnings requirement is last met cannot qualify a person for disability benefits.5

(1) before age 24 must have credit for at least 6 calendar quarters (1 1/2 years) of work under social security during the 3 year period ending with a quarter in which the disability begins.

(2) at ages 24 through 30 must have credit for work under social security in at least one-half of the calendar quarters beginning with the quarter after age 21 and ending with the quarter in which the disability begins.

(3) at age 31 or later must meet two covered work requirements:

(a)

he/she needs 20 calendar quarters (5 years) of work under social security during the 10-year period ending with the quarter disability begins.

(b)

he/she also needs credit for 1 calendar quarter of work for each year after 1950 (or after reaching age 21, if that is later) up to the year disability begins.

In the second instance, the credits may have been earned at any time.

 

1152.1—DWB—DISABILITY REQUIREMENTS

1152.1A—To meet the disability requirements of the law, a widow/widower/ surviving divorced spouse must have a medical condition so severe as to prevent him/her from doing any gainful activity. This condition must last or be expected to last a continuous period of at least 12 months or must be expected to end in death.

1152.1B—To meet the disability requirements of the law, a widow/widower/ surviving divorced spouse must have a medical condition so severe as to prevent him/her doing any gainful activity.

This condition must last or be expected to last for a continuous period of at least 12 months, or must be expected to end in death. (Use one of the optional statements.)

 

Option 1

In addition, the condition must have started no later than 7 years after the death of your/M       's husband/wife. In your/M       's case this requirement will be met until/was last met on   (date).

 

or

 

Option 2

In addition, the condition must have started no later than 7 years after you/ M       last received mother's/father's benefits In your/her case this requirement will be met until/was last met on  (date).

 

or

Option 3

In addition, the condition must have started no later than 7 years after you/ M       last received disabled widow's/widower's benefits. In your /his/her case this requirement will be met until/was last met on   (date).

A medical condition which becomes disabling after the 7-year period cannot qualify a person for disabled widow's or widower's benefits.5

1152.2—DWB—DISABILITY AND SPECIFIED 7-YEAR REQUIREMENTS—GENERAL

A widow/widower/surviving divorced spouse may be considered disabled only if he or she has a physical or mental impairment that is so severe as to prevent a person from doing gainful activity. This disability must last or be expected to last for a continuous period of at least 12 months or must be expected to end in death.

In addition, the disability must have started within a specified 7-year period. It must have started not later than 7 years after the month of death of the wife or husband; or, for a widow, widower or surviving divorced spouse formerly entitled to mother's of father's benefits, no later than 7 years after the month those benefits ended.

For a widow, widower or surviving divorced spouse who was previously disabled and who becomes disabled again, not later than 7 years after the prior period of disability ended.

The 7-year period in your/M       's case ended on  (date) .

A physical or medical impairment which may have become disabling after the latter of these dates cannot qualify a person for disabled widow's, widower's, or surviving divorced spouse's benefits5

 

1152.3—DWB—SEVERE IMPAIRMENT ALLEGED TO HAVE EXISTED IN THE PAST BUT WHICH DOES NOT EXIST AT ANY TIME WITHIN THE SPECIFIED 7-YEAR PERIOD

A medical condition which may have been disabling before but not during the specified period explained above cannot qualify a person for disabled widow's /widower's/surviving divorced spouse's benefits.

 

1154—CHILDHOOD DISABILITY REQUIREMENTS

To be considered disabled for social security purposes a child must be unable to do any substantial gainful work because of a medical condition which has lasted or can be expected to last for a continuous period of at least 12 months or can be expected to end in death. His/Her impairment must be severe enough to prevent him/her from doing any substantial gainful work considering his/her previous training and work experience. The child's disability must have been before age 22.

 

1155—WILLFUL FAILURE TO FOLLOW PRESCRIBED TREATMENT

If a person refuses to follow prescribed treatment without good cause that could restore his/her ability to work, he/she may not become entitled to disability benefits.

 

1156—DIB—EXPLANATION OF CONTINUING ELIGIBILITY

To be considered disabled for social security purposes a person must be unable to do any substantial gainful work because of a medical condition which has lasted or can be expected to last for a continuous period of at least 12 months or can be expected to end in death. His/Her impairment must be so severe as to keep him/her from working not only in his/her usual occupation but in any other substantial gainful work considering his/her previous training and work experience. For a person to remain entitled to a period of disability or disability benefits, he/she must show that his/her disabling condition continues to be severe enough to prevent him/her from doing substantial gainful work.

 

1157—DIB-CDB CESSATION—NOT DISABLED

To be considered disabled for social security purposes, a person's medical condition must be so severe as to prevent him/her from engaging not only in his/her usual occupation but also in any other kind of substantial gainful work, considering his/her remaining functional capacity, age, education, training, and work experience. Disability benefits end when a person is not disabled within the meaning of the law. The law provides, however, that benefits may be continued for 2 months after the month in which the person's condition does not meet the disability requirement.

 

1157.1—DWB CESSATION—NOT DISABLED

A widow/widower/surviving divorced spouse may be considered disabled for social security purposes only if he or she has a medical condition that is so severe that it would prevent him/her from doing any gainful activity. Disability benefits end when a person is not disabled within the meaning of the law. The law provides, however, that benefits may be continued for 2 months after the month in which the person's condition does not meet the disability requirement.

 

1158—DIB-CDB CESSATION—WORK ACTIVITY—TRIAL WORK PERIOD

To be considered disabled for social security purposes, a person must have a medical condition so severe as to prevent him/her from engaging not only in his/her usual occupation but also in any other kind of substantial gainful work, considering his/her age, education, training, and work experience. Disability benefits end when a person is not disabled within the meaning of the law. If a person works while still under a disability, the law provides that benefit payments may continue during 9 months of trial work. Then, if it is determined after the 9 months that he/she has demonstrated his/her ability to do substantial gainful work and therefore is not disabled according to the social security law, his/her benefits are paid for 3 more months.

 

1158.1—DWB CESSATION—WORK ACTIVITY TRIAL WORK PERIOD

A widow/widower/surviving divorced spouse may be considered disabled for social security purposes only if he or she has a medical condition that is so severe that it would prevent him/her from doing any gainful activity. Disability benefits end when a person is not disabled within the meaning of the law. If a person works while still under a disability, the law provides that benefit payments may continue during 9 months of trial work. Then if it is determined after 9 months that he/she has demonstrated his/her ability to do gainful work and therefore is not disabled according to the social security law, his/her benefits are paid for three more months.

 

1159—DIB-DWB-CDB CESSATION—NOT DISABLED VS. WORK ACTIVITY CESSATION

The law provides for ending a period of disability if medical evidence shows that a person can do substantial gainful work or if he/she has demonstrated his/her ability to do such work. When a person has a severe impairment and returns to work, he/she is allowed a trial work period of 9 months in which to demonstrate that he/she can sustain the work activity. If ability to engage in substantial gainful work is demonstrated, disability ceases.

The trial work period may not continue beyond the time it is established that the individual is able to return to work. Benefits are continued for 2 months following the month in which it is determined that the individual was not disabled.

 

1160—VARIATIONS ON LAW PARAGRAPHS

1160A—Whether or not an impairment in a particular case constitutes a disability is determined from all the facts of that case. Primary consideration is given to the effect of an impairment upon an individual's ability to work, as demonstrated by clinical and laboratory findings. Due weight is also given to a person's age, education, and work experience.

(May be used in conjunction with regular law paragraph when unusual emphasis is placed on severity of a person's condition, and/or statements may be made that we have not considered all the evidence.)

1160B—Whether or not an impairment in a particular case constitutes a disability is determined from all the facts of that case. Primary consideration is not given to diagnoses. The primary consideration is the effect of an impairment upon an individual's ability to work, as this is demonstrated by clinical and laboratory findings. Due weight is also given to a person's age, education, and work experience.

(May be used in conjunction with law paragraph when unusual emphasis is placed on a specific diagnosis, e.g., arthritis, as being disabling.)

1160C—Sequential Evaluation Process

Whether or not an impairment in a particular case is disabling is determined from all the facts of the case. However, primary consideration is given to the severity of the impairment as demonstrated by clinical and laboratory findings. In fact, medical considerations alone may determine the issue of disability. When a claimant's disability cannot be determined on medical grounds alone and his/her impairment or impairments prevent him/her from working at his/her regular occupation, his/her age, education, and work experience are considered in deciding whether he/she is able to do other kinds of substantial work.

For example, a marginally educated person who has worked for 35 to 40 years at arduous unskilled labor and can no longer do so may be found to be disabled. Where these specific criteria are not met, whether the person can perform his /her regular or some other type of work is evaluated.

Under the latter type of criteria, a person must be unable to do his/her previous work and also, considering his/her age, remaining functional capacity, education and work experience, unable to do any other kind of work which exists in the national economy. If he/she can do any work which exists in the national economy he/she cannot meet these criteria. This is so regardless of whether such work exists in the immediate vicinity where he/ she lives, or whether a specific job vacancy exists for him/her or whether he /she would be hired if he/she applied for such work.

 

1161—MEDICALLY DETERMINABLE, DEFINITION OF

The social security law specifies that the impairment must be demonstrable by medically acceptable clinical and laboratory diagnostic techniques. Regulations implementing the law require that the medical evidence (signs, symptoms and laboratory findings) be sufficient to enable a reviewing physician to arrive at an independent evaluation as to the nature and limiting effects of the person's impairment, his/her ability to engage in physical and mental activities, and the probable duration of the impairment.

 

1162—SGA, DEFINITION OF

1162A—SGA Earnings Levels for Nonblind

Substantial gainful activity is any work generally done for pay or profit that involves significant duties. (Work may be considered substantial even if performed part-time and even if it pays less or is less demanding than the individual's former work.) In evaluating a person's work activity, we consider the duties of the job, the skill and experience they require and the amount of earnings. (That current work might pay less, be different, and be less complex than what he/she did before the disability began does not necessary mean that he/she would be found eligible for disability benefits.) We ordinarily consider that a person who has earnings averaging more than $300 a month, after deducting disability-related work expenses, is doing substantial gainful work. (Use sentences in parentheses when appropriate.)

1162B—SGA Earnings Levels, Minus Subsidy—For Nonblind

A disability claimant is not entitled to benefits if he/she is able to do substantial gainful work. Whether a person has shown such ability depends on the work the person does in terms of the amount of earnings, skills, responsibility, productivity, hours and duration involved. Earnings averaging more than $300 a month, after disability-related work expenses are deducted, would ordinarily be considered substantial gainful work. However, if his/her pay includes a “subsidy” which reduces the amount of his/her true earnings for the work, only his/her true earnings would be considered. A subsidy would exist, for example, when an employer-because of special consideration for a handicapped person-pays the employee more than the reasonable value of his/her services. This often occurs when a person works in a “protected” or “sheltered” type of employment.

1162C—SGA Earnings Levels, Employees and Self-Employed

Generally, work which results in substantial earnings would show ability to engage in substantial gainful work. However, regardless of the amount of earnings, where the work is discontinued after a short time because of the person's impairment it would not be considered substantial.

 

and

 

Option 1

(a) Earnings average more than $300 a month after deducting disability-related work expenses, ordinarily would show ability to do substantial gainful work. Generally earnings averaging less than $190 a month are not considered substantial.

Earnings average between $190 and $300 a month are not ordinarily consider substantial unless the work is about the same, in amount and quality, as that of other workers in the community who do such work for a living. If the work is the same in amount and quality as that of other workers in the area who do such work for a living, the individual is considered to be doing substantial gainful work.

 

or

 

(b) In determining the ability of a self-employed person to perform substantial gainful work, earnings may not be as important as the extent of his /her activities in the business and his/her supervisory, managerial or advisory services. Earnings or losses from the business may be due to factors other than work activities. For example, a person's work may be considered substantial even if his/her business operates at a loss or earns only a small profit. Generally, a self-employed person's work is considered substantial and gainful if it is reasonably worth over $300 a month to the business or, in terms of total hours, duties and responsibilities, is comparable to that of others in the area who are in similar businesses.

and (where applicable)

 

Option 2

If a person works under special conditions, for example in a sheltered workshop or comparable facility, only earnings based on his/her own productivity (as distinguished from a subsidy based on his/her financial needs or other nonwork factors) are considered. The fact that the “sheltered” institution operates at a deficit and receives charitable contributions or governmental aid does not necessarily mean that a particular employee is not earning his/her salary. However, earnings of $300 a month or less in a sheltered workshop will ordinarily not demonstrate ability to engage in substantial gainful work.

 

1163—FIVE-MONTH WAITING PERIOD

1163A—If you/M       became disabled on       , you/ he/she would not be entitled to disability benefits for any month earlier than       , the sixth full month of disability. The law provides for a 5 calendar month waiting period before disability payments can begin.

1163B—To be entitled to disability benefits a person must be disabled throughout the 5-calendar month waiting period. Thus, it is often necessary to get medical evidence near the end of the waiting period to decide whether this requirement has been met.

1163C—A claim for disability benefits may be filed at any time after disability begins and can often be processed before the waiting period expires. We do not ordinarily defer action on the claim until the end of the waiting period. In fact, we encourage early filing, and many people who file during the waiting period get their first check the third day of the month following the first month of entitlement.

 

1164—EXTENDED PERIOD OF ELIGIBILITY

If a person who still meets the disability requirement becomes unable to work again within 15 months after 9 months of trial work, the monthly benefits can be started again in most cases. A new application is not needed.

 

1170—INABILITY TO ENGAGE IN SGA NOT ESTABLISHED—DIB or CDB CLAIMANT CONFINED TO HOSPITAL, INSTITUTION, ETC.

The fact that a person is confined in a hospital/institution/       does not, in itself, establish that he/she is disabled as defined by the social security law. To be considered disabled for social security purposes, a person must be unable to work because of a medical condition which has lasted or can be expected to last for a continuous period of at least 12 months or can be expected to end in death, in making a disability determination consideration is given to the individual's remaining functional capacity, age, education, training, and work experience as well as to the severity of his/her impairment. Disability is established when the evidence based on all of these factors shows that the individual is unable to perform substantial gainful work. Even though a person is confined to a hospital/ institution/       the evidence must still establish that it is his /her medical condition and not his/her confinement that is preventing him /her from engaging in substantial gainful work

E. Adjudicative Process Paragraphs

 

1200—DETERMINATION MAKING PROCESS

In deciding disability claims, our goal is to apply the social security law with equity and consistency to all claimants. A determination as to whether the claimant's medical condition makes him/her unable to engage in substantial gainful work is made by an agency in the State in which the claimant lives. Physicians and other trained disability evaluation personnel in this agency participate in making the determinations. The decision is then subject to review by physicians and adjudicative personnel of the Social Security Administration. Thus, a disability determination represents a composite of the efforts of experienced personnel at both the State and Federal levels. Further, when an application for reconsideration of the disability determination is filed, the reconsidered determination is made by persons other than those involved in the initial decision.6

 

1201—RECONSIDERATION—RATIONALE FOR RECONSIDERATION PROCESS

The reconsideration determination as an important first step in the appellate process. When a dissatisfied claimant requests reconsideration, he/she is given the opportunity to express the reasons for his/her dissatisfaction and is encouraged to provide additional information in support of his/her claim. The information of record is verified and updated, and any new leads are fully explored and developed. The aim of the reconsideration process is to make a decision on the basis of a completely independent review of a claim by a disability examiner/physician team different from the one that made the initial decision.

F. Procedural and Informational Paragraphs

 

1250—ADEQUATE MEDICAL EVIDENCE

Adequate medical evidence is fundamental to disability evaluation. The reports furnished by attending physicians and other treating sources on behalf of their patients are of great significance and are highly regarded since they can reveal the history of the person's medical problem, the type of treatment he/she has received, and the results of therapy. Often such information from sources of treatment is sufficient for a decision to be made.

In other cases the reviewing physicians on the staff of the State agency find that in order to establish the extent of the person's impairment special examinations are needed. In such cases the examinations are obtained at government expense from physicians practicing in or near the community where the person resides. (In your/M       's case, it was felt that a special/an additional examination was necessary to resolve the complex medical issues involved in your/his/her claim.)

 

1251—CLAIMANT'S RESPONSIBILITY FOR FURNISHING MEDICAL EVIDENCE

Under the law, a claimant for social security disability benefits has the responsibility for furnishing some evidence of his/her disability. When a person applies for disability benefits, the people in the Social Security office will explain the person's responsibility for furnishing medical evidence.

 

1252—DISSATISFACTION WITH CONSULTATIVE EXAMINATION

You/M       have/has expressed some dissatisfaction with the manner in which the special medical examination arranged for you/him/her by the State agency was conducted. The State agency is responsible for making disability determinations and also for deciding what medical evidence or other information may be necessary to insure a proper determination. Many times special examinations may be ordered to obtain medical information essential for evaluating the extent of the individual's impairment which is not available from the attending physician or to reconcile inconsistencies among reports furnished by the claimant's medical sources. The examination mentioned by you/M       was arranged by the State agency for that purpose. Therefore, we are bringing your/his/her comments about the examination to the attention of the State agency for their consideration in the further handling of your/his/her case.

 

1253—ATTENDING PHYSICIAN'S CONCLUSION (GENERAL)

In deciding this case careful consideration was given to the conclusion of your /M       's attending physician. We value the evidence received from the attending physician highly and are reluctant to reach a decision which is not consistent with their conclusion. However, in our program an independent determination must be made as to whether the person meets the requirements of the law and the regulations on the basis of the relevant medical findings of all examining physicians, results of laboratory studies, treatment given and response, as well as the individual's age, education, training and work experience. 7 Where judgments differ as to the effects of impairments, the decisions must be based on the evidence presented.

 

1254—ATTENDING PHYSICIAN'S CONCLUSION (SPECIFIC PHYSICIAN)

In reaching the decision in this case, careful consideration was given to Dr.       's conclusion that you/M       are/is disabled. The Social Security Administration is responsible for making an award of disability benefits only where it is shown that a person is unable to work because of a “medically determinable impairment.” This means that a person's disability must be demonstrated by clinical and laboratory findings. In cases where judgments of physicians differ as to the effects of an impairment, a determination regarding the person's ability to function must be made based on the evidence.

We value the evidence furnished by attending physicians highly and are reluctant to reach a decision which is not consistent with their conclusions. Nevertheless, we must do so when the total evidence of record shows the person does not meet the requirements of the law.

 

1255—CLAIMANT MENTIONS INABILITY TO DO FORMER WORK

You/M       mentioned that your/his/her former employer will not permit you/him/her to do your/his/her usual job as       . We recognize that a person may be unable to do a job held prior to his /her ailment. However, to be considered disabled for social security purposes, a person must be unable to do any substantial gainful work. In determining whether he/she is able to work, we consider the restrictions imposed by his/her impairment, his/her remaining capacity to work, and the qualifications resulting from his/her age, education, previous training and work experience.

 

1256—CLAIMANT MENTIONS INABILITY TO FIND SUITABLE WORK

1256A—Many factors, both medical and nonmedical, bear on a person's ability to work. Among these are the person's age, education, training, and previous work experience, as well as to the severity of his/her medical impairments. However, under the disability provisions of the Social Security Act, unemployment must be primarily due to a physical or mental incapacity to do any type of substantial gainful work. We understand how difficult it may be for someone with your/M       impairments to find suitable work when faced with employer hiring practices and local economic conditions. Nonetheless, lack of ability to do a job, as distinguished from lack of ability to get a job, is essential to a favorable determination.

1256B—It is recognized that you/M       may encounter difficulty in finding suitable employment. However, a person may become unemployed or remain unemployed for a number of reasons other than disability, i.e., individual employer hiring practices, technological changes in the industry in which the person has been employed, local or seasonal business or economic conditions, and many other. The disability provisions are intended to benefit only those persons who are not working because of incapacity, rather than those unemployed because of other factors.

 

1257—CLAIMANT MENTIONS LACK OF JOB OPPORTUNITIES IN HIS LOCALITY

In deciding whether there are jobs which the applicant can do, we consider the number and variety of jobs available in the national economy. This means that we consider whether he/she can do jobs which exist in reasonable numbers in the region where he/she lives or in other regions of the country. That a specific job may not be open in a particular industry at a given time would not permit us to find, on that account alone, that a person is unable by reason of his/her impairment to engage in any substantial gainful work. The evidence must show that he/she is not only unable, by reason of a physical or mental impairment, to perform the type of work he/she previously did, but that he/she is also unable to do any other type of substantial gainful work, considering his/her age, remaining functional capacity, education, training and experience.

 

1258—ADVICE RE INABILITY TO ENGAGE IN SGA

If your/M       's condition should continue to prevent you/him /her from doing any substantial gainful work, you/he/she should get in touch with any Social Security Office.

 

1259—ADVICE RE FUTURE DECISION TO FOLLOW PRESCRIBED TREATMENT

If you/M       should decide to follow the prescribed treatment or if you/he/she have/has more information showing why you/he/she should not, please get in touch with any Social Security Office.

 

1260—ADVICE RE WORSENING OF CONDITION

According to the amount credited to your/M       's social security record at the time you/he/she filed your/his/her application, you/he/she will continue to meet the earnings requirement for disability purposes until       . If your/his/her condition should get worse before this date and prevent you/him/her from doing any substantial gainful work, you/he/she should get in touch with any Social Security Office.

 

1261—ADVICE RE WORSENING OF CONDITION—CESSATION CASE

If you/M       become/becomes unable to work again, you/he/ she should get in touch with any Social Security office about filing another disability application. The disability period already established for you/him /her may still be used to your/his/her advantage in deciding whether furture benefits can be paid on your/his/her social security record and is figuring the amount of such benefits.

 

1262—ADVICE RE WORSENING OF CONDITION—CESSATION CASE—REFERENCE TO NO WAITING PERIOD

The disability period already established for you/M       may still be used to your/his/her advantage in deciding whether future benefits can be paid on your/his/her social security record and in figuring the amount of such benefits. If you/M       become(s) unable to work again you/he/she should get in touch with any Social Security office about filing another disability application. If a new period of disability is established, you/he she may be entitled to benefits without a 5-month waiting period.

 

1263—RECONSIDERATION PARAGRAPHS

1263A—Claimant Being Notified of Decision Concurrently With Reply to Member to Congress

M       is being notified of this decision and that he/she may request a reconsideration within 60 days after he/she receives the decision notice. The people in any Social Security office will be glad to help him/ her with the necessary written request.

1263B—Claimant Notified Prior to Reply to Congress-No Indication in Correspondence From Member of Congress That He/She is Aware of This Notification.

If M       may request a reconsideration of his/her application. The people in any Social Security Office will be glad to help him/her with the necessary written requests.

 

1264—HEARING PARAGRAPHS

1264A—Claimant Being Notified of Decision Concurrently With Reply to Member of Congress

M       is being notified of this decision and that he/she has 60 days from the date of receipt of the denial notice in which to request a hearing before an administrative law judge of the Office of Disability Adjudication and Review. The people in any Social Security Office will be glad to help him/ her with the necessary written request.

1264B—Claimant Notified Prior to Member of Congress—No Indication in Correspondence From Member of Congress That He/She is Aware of This Notification

If M       may request a hearing before an administrative law judge of the Office of Disability Adjudication and Review. The people in any social security office will be glad to help him/her with the necessary written request.

1264C—Claimant Previously Notified-Member of Congress Aware That Claimant Received Notice, But Member of Congress Does Not Have a Copy

When M       was notified of the decision, he/she was advised that he/she could request a hearing before an administrative law judge of the Office of Disability Adjudication and Review. The people in any Social Security Office will be glad to help him/her with the necessary written request.

1264D—Claimant Previously Notified-Member of Congress Encloses Correspondence Which Includes a Copy of the Notice

As M       was informed, he/she may request a hearing before an administrative law judge of the Office of Disability Adjudication and Review. The people in any Social Security Office will be glad to help him/her with the necessary written request.

 

1265—CLAIMANT DID NOT APPEAL INITIAL DECISION

You/M       were/was notified of the decision to deny your/his /her application on       . You/He/She were/was also advised of your/his/her right to request a reconsideration within 60 days from the date of receipt of the denial notice. Our records do not show that you /he/she requested a reconsideration. If you/M       have/has any further questions, the people in any Social Security Office will be glad to help you/him/her in any way possible.

 

1266—CLAIMANT DID NOT APPEAL RECONSIDERATION DECISION

You/M       were/was notified of the reconsideration decision on       . You/He/She were/was also advised of your/his/her right to request a hearing before an administrative law judge of the Office of Disability Adjudication and Review within 60 days from the date of receipt of the denial notice. Our records do not show that you/he/she requested a hearing. If you /M       have/has any further questions, the people in any Social Security office will be glad to answer them and assist you/him/her in any way possible.

 

1267—HEARING PENDING

We are forwarding your/M       's letter to our Office of Disability Adjudication and Review. That office has the latest records on your/M       's claim for disability benefits. You/He/She should hear from that office soon.

 

1268—NO DETERMINATION MADE AS TO DISABILITY

No determination was/has been made as to whether you/M       are /is disabled. A condition that occurs or becomes disabling after the earnings requirement is last met may not qualify an individual for disability benefits.

 

1269—SUBSEQUENT APPLICATION—NO DETERMINATION MADE AS TO DISABILITY

When you/M       filed your/his/her latest application, we carefully reviewed the previous decision and could find no basis for changing it. No decision was/has been made as to whether you/M       are /is disabled, since an impairment which occurs or becomes disabling after the earnings requirement is last met may not qualify an individual for disability benefits.

 

1270—AUXILIARY BENEFICIARIES

No benefit may be paid to the wife, husband, or child of a wage earner or self-employed person unless he/she is entitled to disability benefits.

 

1271—ANOTHER DISABILITY PROGRAM MENTIONED

Definitions of disability are not the same in all government and private disability programs. Government agencies must follow the particular laws which apply to their disability program. Therefore, a finding by a private organization or another government agency that a person is disabled would not necessarily mean that he/she meets the disability requirements of the Social Security Act.

 

1271.1—FAVORABLE DISABILITY DETERMINATION BY ANOTHER AGENCY/PROGRAM

There are many disability programs, government and private, under which an individual may become entitled to disability benefits on the basis of a physical or mental impairment. Although some of the programs are similar, each one must be guided by the eligibility rules under its own laws. In making a disability determination for social security purposes, the findings of other government agencies and private organizations as well as the conclusions of attending physicians are carefully considered. However, to be eligible under social security, the disability requirements specified in the Social Security law must be met. Thus, a finding of disability by another government agency or by a private organization would not necessarily mean that the person would be found disabled within the meaning of the Social Security Act.

 

1272—P&T PENSION AWARD BY VETERANS' ADMINISTRATION

The fact that you/M       were/was found permanently and totally disabled under the Veterans' Administration program was carefully considered along with the other evidence in your/his/her case. However, a determination by the Veterans' Administration that a person is permanently and totally disabled does not necessarily mean that he/she qualify under the disability provisions of the Social Security Act. Although there are many similarities, the eligibility requirements under the disability programs administered by the Veterans Administration and by the Social Security Administration are not the same. We must determine whether you/M       meet/meets the disability requirements in the social security law.

 

1273—INDIVIDUAL COMPLAINS ABOUT OTHERS WITH SAME IMPAIRMENT RECEIVING BENEFITS

The decision as to whether an individual is under a disability is made on the basis of the evidence in each case. Thus, two applicants for benefits may appear to have a similar type of impairment, but the determination for each may differ because of differences in actual clinical findings, results of laboratory studies, response to treatment and vocational factors such as age, previous training and work experience.

 

1275—REFERRAL TO VR FOR REHABILITATION SERVICES

The Social Security Administration and the State vocational rehabilitation agencies work closely together to assure that all claimants for disability benefits are considered vocational rehabilitation services. However, even though all claimants are considered for services, not all are accepted for services by the vocational rehabilitation agencies.

There are a number of factors which affect the vocational rehabilitation decision which may relate to the individual's ability to work or the severity of his/her handicapped. In some instances, the vocational rehabilitation agency may consider that the individual,even though handicapped, is adequately trained and qualified for work. Sometimes, the work or training suitable the claimant is not available within his/her immediatel community. Occasionally, the restrictions placed upon his/her/activities and the claimant's mobility preclude the development of a realistic plan or sevices. There are occasions when an individual who is considered as empoyable or trainable must defer training until some other problem, as the need for corrective medical treatment, has been resolved..

 

1276—PURPOSE OF DIB—INSURED STATUS REQUIREMENTS

Disability insurance benefits are intended to replace in part, earnings that are lost when disability prevents a person from working. The disability insured status requirements are designed to limit disability protection to persons who have had sufficiently long and sufficiently recent covered employment to indicate that they have been dependent upon their earnings. This relates the protection afforded by the disability provisions to loss of earnings on account of disability. Considering this purpose, the insured status requirements provided in the law are reasonable. No matter what requirements are set, there would, of course, be some persons who fall short of meeting them.

 

1277—REPLY TO REQUEST FOR LOWERING THE AGE AT WHICH RETIREMENT BENEFITS ARE FIRST PAYABLE

Benefits under the social security program are intended to be made available at an age when it can be assumed that a large number of people, for health or other reasons, may not be able to work. Under the present law, retirement benefits are available to workers and their wives or husbands at age 62, with the benefits of those who start getting them before full retirement age reduced to take account of the longer period over which the benefits will be paid. The reason for the reduction in benefits is to make some payment available earlier than full retirement age at no additional cost to the program. If benefits were made available earlier than age 62 with no additional cost to the program, there would have to be an even further reduction in the benefit amount. On the other hand, if full social security retirement benefits were made available much earlier than at full retirement age e.g., at full retirement age, the cost of the social security program would be substantially increased.

 

1278—ELIGIBILITY FOR RIB AT AGE 62

Although you/M       do/does not qualify for disability benefits, our records show you/he/she have/has enough credit for work under social security to qualify for retirement benefits. The Social Security Act provides that workers may qualify for retirement benefits starting at age 62. If they choose to receive benefits before they become full retirement age, however, the amount of the benefit is permanently reduced. If you/M       would like further information about this, you/he/she should contact any social security office. The representatives in that office will be glad to help you/him/her.

 

1279—REFUND OF SOCIAL SECURITY CONTRIBUTIONS

The law does not provide for refunding social security contributions to workers who do not qualify for benefits. These amounts remain in the trust funds and are used to pay benefits and the administrative cost of the program. There are several reasons why refunds are not made. In many instances, there is a possibility that a worker will later become eligible for retirement benefits.

Also, a person who has contributed to the program generally has a period of survivor protection in the form of a possible benefit to his/her survivors should he/she die. If his/her contributions were refunded, this protection would have been furnished with little or no cost to him/her. Persons who do not work long enough to have a period of protection for their survivors ordinarily have not contributed a great deal to the social security program, and the processing of refunds would be expensive considering the size of the sums involved.

 

1280—INDIVIDUAL IN NEED OF FINANCIAL ASSISTANCE

If you/M       need/needs financial help, you/he/she may wish to contact your/his/her local public assistance office. Even if you/ he/she are/is not eligible for aid, the people there may know of another public or private agency in the community which helps people in your/M        's circumstances.

 

1281—EXPLANATION FOR PROCESSING TIME—OBTAINING MEDICAL EVIDENCE

We understand your/his/her concern about delays in the processing of disability claims. Disability claims are most often delayed to get medical evidence which will clearly show how severe the claimant's condition is and how it affects his/her ability to work. We have found that the best way to get this information is to get reports from the claimant's treating sources. However, with the many pressures bearing on physicians, clinics, hospitals and various agencies, delays are often encountered in securing the information. Most decisions can be made on the basis of the evidence received from the treating sources, but in some cases an additional medical examination may be required. This examination is usually performed by a consultative physician at government expense. There are scheduling difficulties in some instances, and reports of the examination may be delayed.

 

1282—EVALUATION—USE OF LISTINGS

The Listing of Impairments was designed to simplify the evaluation of disability and to insure similar decision in similar cases. It describes for each of the major body systems sets of symptoms, signs, and laboratory findings that are expected to prevent work for a year or longer. However, where the criteria in the Listing of Impairments are not met, an individual can still be found to be disabled if he/she has a physical or mental impairment which, considering such factors as his/her age, education, training, and work experience, is severe enough to prevent him/her from engaging in substantial gainful activity for a continuous period of at least 12 months.

G. Railroad Employment Paragraphs

 

1300—GENERAL EXPLANATION TO WAGE EARNER

A period of disability has been established for you/M       based on your/his/her combined credits from railroad and social security employment. However, you/he/she do/does not have enough social security credits alone to qualify for monthly disability benefits.

Under the Social Security Act, railroad earnings are creditable as social security credits or earnings for the purpose of establishing a period of disability. The law also provides that railroad retirement credits used by an individual to establish eligibility for a railroad retirement or disability annuity cannot be used as social security credits for social security disability benefit purposes.

We are notifying the Railroad Retirement Board of the period of disability established for you/him/her. They will determine if you/he/she are/ is entitled to an increase in your/his/her railroad annuity.

 

1301—NOT INSURED UNDER SOCIAL SECURITY

A person may eligible for benefits under both the railroad retirement and the social security programs if the eligibility requirements of both systems are met. However, benefits will be combined in one monthly payment which will be administered by the Railroad Retirement Board.

To qualify for railroad retirement benefits, a person needs 10 years (120 months) of railroad service.

According to the date of birth given on your/M       's application, you/he/she need/needs       quarters of coverage to be insured for social security benefits. Our records show you/he/she now have/has       quarters.

 

1302—FREEZE ESTABLISHED—NOT ELIGIBLE FOR DIB

A period of disability has been established for you/M       beginning       . It will continue until you/he/she are/is not disabled or reach/reaches full retirement age, whichever occurs first.

An examination of your/M       's earnings record shows that you/ he/she meet/meets the earnings requirement primarily on the basis of railroad retirement credits and not on earnings covered by the Social Security Act. This means that you/M       qualify/qualifies for a period of disability but not for disability benefits under the Social Security Act.

The law does not permit the use of railroad retirement credits for the payment of social security disability benefits if an individual is receiving, or may receive, benefits from the Railroad Retirement Board based on such credits.

 

1303—FREEZE ESTABLISHED—NOT ELIGIBLE FOR DIB—MAY BE ELIGIBLE FOR RIB AT AGE 62

While you/M       are/is not eligible for social security disability benefits, you/he/she may be eligible for retirement benefits at age 62, if your/his/her disabling condition remains severe enough to prevent you/him/her from doing any substantial gainful work until then.

The value of a determination of disability to railroad employees such as you/ M       is that it frequently results in an increase in the benefits payable by the Railroad Retirement Board. We have informed the Railroad Retirement Board of the determination of disability. They will review your/ his/her file and inform you/him/her of any change in your/his/her railroad retirement disability benefits.

 

1304—INSURED FOR RIB AT FULL RETIREMENT AGE

Even though you/M       are/is not insured for disability benefits, the period of disability established for you/him/her helps protect your/his/her future benefit rights and the rights of your/his/ her dependents and survivors. If your/his/her disabling condition continues until you/he/she reaches full retirement age, the social security credits now on your/his/her social security record are sufficient to give you/him/ her an insured status. A retired worker who has at least 120 months (10 years) of railroad service and who has enough work under social security to qualify for social security payments may receive retirement benefits under both the railroad retirement and the social security system.

 

1305—NOT A CAREER RAILROAD WORKER

When an individual has less than 10 years of employment covered by the Railroad Retirement Act, no railroad retirement annuity is payable. His/Her earnings, together with any earnings he/she may have received in employment covered by the Social Security Act, are used in determining whether he/she is eligible for social security benefits.

 

1306—W/E HAS 120 MONTHS RR SERVICE

We note that your/M       's railroad earnings records indicate that you/he/she have/has at least 120 months of railroad work which makes you/him/her eligible to apply for disability benefits under the disability provisions of the Railroad Retirement Act. If you/he/she have/ has not already done so, you/he/she may wish to communicate with the Railroad Retirement Board regarding the filing of an application for disability benefits under the Railroad Retirement Act.

H. Closing Paragraphs

 

1350—CASE IN OR BEING SENT TO DISTRICT OFFICE

1350A—We are informing M       's social security office of your interest in his/her claim. We are also asking the people there to complete their action and  (1) or (2) as soon as possible. We will get in touch with you when we have more information.

(1) return his/her records to us

(2) forward his/her records to the State agency

1350B—We are including copies of our correspondence in M       's records to let his/her social security office and the State agency know of your interest. Every effort will be made to complete the action on the claim as quickly as possible. We will notify you promptly when a decision is reached.

 

1350.1—CASE IN OR BEING SENT TO DISTRICT OFFICE—(INITIAL DETERMINATION COMPLETED)

We have requested/are requesting the people in M       's social security office to get in touch with him/her personally to explain the determination. They will also explain his/her right to file a request for reconsideration and will assist him/her in obtaining any additional evidence. If M       requests reconsideration of his/her claim, he /she will be given every opportunity to present his/her case anew for redetermination.

 

1351—CASE IN OR BEING SENT TO DDS

1351A—The State agency is being/has been informed of your interest in this case.8 You may be assured that the claim will be given every consideration and a decision will be made as soon as possible. You will, of course, be notified of the decision.

1351B—We are requesting the State agency to complete action on this case and to return M       's records to us as soon as possible. We will write you again when additional information is available.

1351C—We assure you that your/M       's application is being given every consideration. As soon as  (1) or (2), we will notify you/him/her.

(1) a decision is made

(2) it has been re-evaluated

1351D—We regret the delay this action will cause. The additional consideration given could, however, have a bearing on the final decision. As soon as the records are returned, you will be notified of the decision reached on your/M       's claim.

 

1352—REQUEST FOR HEARING FILED

(See Sample letters in Section 2417.)

 

1353—CLAIMANT SHOULD CONTACT DO WITH FURTHER QUESTIONS

If you/he/she have/has any further questions, the representatives in your /his/her social security office will be glad to help you/him/her.

 

1354—INFORMATION BEING FURNISHED TO THIRD PARTY

Similar information is being furnished       who also inquired on M       's behalf.

 

1355—COOPERATE WITH DDS IF CONTACTED BY THEM

If a representative of the State agency gets in touch with you, your cooperation will help speed the handling/review of your claim.

 

1356—ADDITIONAL INFORMATION SHOULD BE SENT TO DISTRICT OFFICE

Any additional information that you wish to submit should be sent to your social security office.

 

1357—ACTION ON CLAIM WILL BE COMPLETED AS SOON AS POSSIBLE

You may be sure that action on your/M       's claim will be completed as soon as possible, and we will notify you when we have further information.

I. Medicare Paragraphs

 

1360—LAW PARAGRAPHS

1360A—The 1972 amendments to the Social Security Act provide Medicare coverage for individuals entitled to social security disability benefits. Such beneficiaries will be enrolled in the 25th month of entitlement.

1360B—There are no provisions in the law for Medicare coverage for dependents under age 65, except those who are entitled to disability benefits or those who have chronic kidney disease which requires long-term dialysis or a kidney transplant. Therefore, M       /you/your wife/your children is /are not eligible for Medicare coverage at this time.

1360C—To qualify for hospital and supplementary medical insurance, a person must 1) be age 65 or over and meet certain other insured, citizenship or residency requirements, or 2) be disabled and entitled to disability insurance benefits for 24 months, or 3) need long-term dialysis treatment for chronic kidney disease or require a kidney transplant and either have worked long enough under social security to be insured, be getting monthly benefits, or be the wife, husband or child of an insured person or beneficiary.

According to our records M       /you does/do not meet either of the above requirements. Therefore, eligibility for Medicare cannot be established at this time.

1360D—To qualify for hospital and supplementary medical insurance benefits as a spouse, an individual must meet one of the following requirements:

  1. be age 65 or over and the spouse of a person receiving social security benefits; or

  2. need long-term dialysis treatment for chronic kidney disease or require a kidney transplant and be getting monthly benefits or be the spouse of an insured person or beneficiary.

According to our records, neither of the above requirements are met in his/ her/your case. Therefore, eligibility for Medicare cannot be established at this time.

 

1361—FUTURE ENTITLEMENT

1361A—Our records show that you became entitled to disability benefits beginning  month/year. Therefore, in accordance with the above provision, you will become eligible for Medicare coverage in  month/ year . Enrollment in Medicare is automatic and you will be notified when you have been enrolled.

1361B—If you believe you are eligible for Medicare, and you do not receive a notice that you have been enrolled by  Designate A or B.

  1. the time you have been entitled to disability benefits for 22 months. (Note: this fill-in to be used when MOE to DIB is unknown.)

  2.  month/year (Note: Show the month/year which is 2 months before entitlement to HI-SMI) you should get in touch with any social security office. Most questions can be handled by telephone or mail. If you visit an office, please take this letter with you.

     

1362—ENROLLMENT AND PREMIUMS

1362A—You will be automatically enrolled for Medicare coverage in the 25th consecutive month of your entitlement to disability insurance benefits. We will notify you by mail when you have been enrolled.

1362B—You are automatically entitled and enrolled for hospital insurance and there is no premium to pay for this coverage.

1363C—The premium for the supplementary medical insurance is       monthly and this will be deducted from your social security benefit checks beginning (fill in A or B).

  1. in the month in which you qualify for coverage.

  2. month/year

1362D—Although you are entitled to both railroad and social security disability benefits, the cost of your supplementary medical insurance will be deducted from your railroad retirement benefits.

1362E—If you are entitled to disability insurance benefits but your benefits have been suspended, you will be billed quarterly for the premiums for the supplementary medical insurance.

1362F—Premiums for the medical insurance program under social security are due prior to the period for which protection is furnished. This procedure follows ordinary private insurance practice. In carrying out this policy, it is necessary to deduct the premium from the checks which people receive early in a month to cover protection for that month. Thus, the deduction made from the check you received on  (month) third was for medical insurance protection beginning with that month.

1362G—Although you did not elect supplementary medical insurance, the State of          has determined that you are eligible to have your premium paid by the State. Therefore, you should keep the health insurance card which shows entitlement to both health and medical insurance.

1362H—A State may provide supplementary medical insurance for certain persons through a “buy-in” agreement with the Secretary. Under the terms of the law and the agreement, the State must enroll all individuals who are or become members of the coverage group specified in the agreement if they are eligible for supplementary medical insurance. All persons meeting those requirements are enrolled and have their premiums paid by the State for each month of their coverage period. An individual enrollment under a State buy-in agreement is involuntary. The State may enroll a person even though he/she does not wish to enroll and he/she cannot terminate State buy-in coverage.

1362I—Beneficiaries living in Puerto Rico are automatically entitled to hospital benefits if they are entitled to social security disability benefits. If you want the supplementary medical insurance you should contact any social security office.

1362J—Beneficiaries living outside the United States are entitled to hospital insurance if they are entitled to social security disability benefits. If you want the supplementary medical insurance, you must file an enrollment request with any social security office.

1362K—You may enroll for supplementary medical insurance during a “general enrollment” period. There is a general enrollment period every year—from January 1 through March 31. If you enroll during this period, your coverage beings with the next July.

 

1363—REFUSALS AND CANCELLATIONS

1363A—If you do not want the supplementary medical insurance, you must complete the card included with the notice.

The card must be returned to us by the date specified on it. If you later change your mind, you can still have this protection if we are notified before the end of the 3rd month after the month shown on your card. If you wait a year or longer, your monthly premium will be 10 percent higher for every 12-month period that you could have had medical insurance but did not enroll. You may also sign up for supplementary medical insurance at age 65 and pay the premium in effect at that time.

1363B—Medical insurance can be cancelled at any time by filing a written notice. Your protection and your obligation to pay premiums will stop at the end of the calendar quarter after the quarter in which your notice is received. (A calendar quarter is any of the 3-month periods beginning with January 1, April 1, July 1 or October 1.)

1363C—If you do cancel your medical insurance, you may re-enroll in any “general enrollment” period from January 1 through March 31 each year and coverage would begin the following July 1.

 

1364—MEDICARE COVERAGE FOR KIDNEY DISORDERS

1364A—A provision of the Social Security Act extends full Medicare coverage to people with chronic kidney disease who require long-term dialysis or kidney transplant. To be eligible for the coverage the individual must be insured for, or entitled to, monthly social security benefits, or annuity under the Railroad Retirement Act, or be the husband, wife, or dependent child of an insured or entitled individual. Covered benefits will include those under both the hospital insurance and the supplementary medical insurance parts of the Medicare program.

1364B—Eligibility for benefits will begin with the third month after the month in which a course of dialysis is begun. It will continue through the twelve months after dialysis ends or 36 months after a transplant. Because of the 3-month waiting period only those persons with chronic conditions requiring long-term dialysis or transplant will qualify under this particular provision.

1364C—The provision authorizes the Secretary to limit reimbursement under Medicare for kidney transplant and dialysis to kidney disease treatment centers which meet regulatory requirements. These requirements must include a minimal utilization rate for covered procedures and a medical review board to screen the patients for the proposed treatment procedures.

 

1365—MEDICARE COVERAGE EXCLUSIONS

1365A—Not all medical services and supplies can be paid for under the Medicare program. Some items which may not be paid for include prescription drugs not other medicines, eyeglasses and examinations for prescribing, fitting or changing eyeglasses, and dentures and routine dental care.

 

1366—OTHER MEDICAL INSURANCE PLANS

1366A—We cannot provide you with a statement that you are not entitled to Medicare because our records show that you have been entitled to disability benefits for at least 24 months. Therefore, you are entitled automatically to hospital insurance coverage. You are also entitled to medical insurance unless we receive notice that you do not want it.

1366B—We cannot advise you whether to enroll for supplementary medical insurance. We suggest that you contact your insurance company for information about the effect of Medicare on your other insurance.

1 If it is apparent that the individual inquiring on behalf of the claimant is unaware of the basis for our previous denial, begin paragraph with the following sentence: “M         's application for disability benefits was denied because the evidence did not show him/her ( see 1104(1) through (6).)

2 Use when CO or DAB has reviewed.

3 Use when CO or DAB has reviewed the cessation.

4 Use “when our disability staff” when CO or DAB has reviewed the cessation.

5 This sentence may be omitted from this paragraph and included in the rationale of the letter if it appears more appropriate.

6 Use last sentence when a reconsideration request is filed.

7 In DWB cases, omit the underlined words.

8 If the DDS has already been advised of special interest, e.g., a status report has been requested, use “has been informed” rather than “is being informed.”


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