Identification Number:
DI 12027 TN 1
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Statutory Benefit Continuation (SBC)
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 120 – Appeals Processing
Subchapter 27 – Statutory Benefit Continuation (SBC)
Transmittal No. 1, 01/25/2019

Audience

PSC: CS, DE, DEC, DTE, ICDS, IES, ISRA, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, CR, ERE, FCR, FDE, RECONE, RECONR, RECOVR;
OCO-ODO: BET, CR, CST, CTE, CTE TE, DE, DEC, DS, PETE, PETL, RCOVTA, RECONE, RECOVR;
ODD-DDS: REF;
FO/TSC: CS, CS TII, CS TXVI, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;
OHO/OAO: OHAAC, OHACO (SAWDY), OHAHOs, OHAROs;

Originating Component

ODP

Effective Date

01/26/2019

Background

The Unprocessed Medical Cessation (UMC) workgroup implemented a system update adding functionality enhancements to SSA systems. The enhancements include additional screens, tickles, and functionality in Disability Control File (DCF) , new information exported from the Electronic Disability Collect System (EDCS) to the DCF, and improved case monitoring for continuing disability review (CDR) appeals via Management Information (MI) Central. These new instructions and processes are designed to reduce the need for manual action and further automate the medical CDR appeal process. This Program Manual Online System (POMS) update is apart of the UMC modernization project, and explains the new system actions required to process statutory benefit continuation (SBC) requests.

Summary of Changes

DI 12027.010 Processing Statutory Benefit Continuation (SBC)

We updated section C to reflect the new business process for processing SBC request via SSA systems. Our update includes an explanation of the new functionality in the EDCS program and the use of the EDCS Exclusion Appeal Screen (EEAI) screen available via the Disability Claims File SSA systems new to SBC processing.

 

DI 12027.010 Processing Statutory Benefit Continuation (SBC)

The individual affected will receive a medical cessation notice (or notice of a medical adverse reopening/revision determination) about the adverse action. The notice will provide information about contacting the field office (FO) to request appeal and the option of SBC. The individual may choose to elect or decline SBC.

A. Policy - Who May Sign the SBC Election Form

  • The beneficiary eligible for SBC must sign the appropriate election form, unless he/she is incompetent or a minor child.

  • Once an appeal of the medical cessation (or medical adverse reopening/revision determination) is filed, the beneficiary’s representative payee may sign the appropriate election form because the beneficiary and payee will both be responsible for repayment of any overpayment.

  • An authorized representative (attorney or non-attorney) may not sign the election form on the beneficiary’s behalf because an authorized representative will not be responsible for repayment of any overpayment.

  • If an authorized representative signs an election form and it is filed timely, it will serve as a protective writing for SBC if a properly signed election statement is later submitted. The beneficiary (or representative payee, where appropriate) must sign an appropriate election form for the beneficiary to receive SBC.

B. Procedure – When Individual Contacts FO Regarding SBC

When an individual receives his/her medical cessation notice (or notice of a medical adverse reopening/revision) informing him/her of the adverse action, he/she may contact the FO by telephone, mail or office visit.

In each of these methods of contact, the FO will:

1. Explain SBC Requirements to the Individual

  • Statutory Benefit Continuation (SBC), DI 12027.001

  • Who May Elect Statutory Benefit Continuation (SBC), DI 12027.007

2. Explain the Appeal Information to the Individual for His or Her Appropriate Appeal Level

  • Reconsideration — Medical Cessations and Favorable Initial and Reconsidered Determinations Revised Due to Medical Reasons - Title II and Title XVI, DI 12026.001DI 12026.025

  • Request for Administrative Law Judge (ALJ) Hearing, DI 12010.001

    NOTE: The FO processes requests for ALJ hearings of continuing disability issues exactly as they process requests for ALJ hearings on initial claims.

  • Requesting Appeals Council (AC) Review, DI 12020.001.

3. Explain the Time Limits for Both SBC and Appeals to the Individual

  • See Evaluating the Time Limit for Electing Statutory Benefit Continuation (SBC), DI 12027.008

  • See Time Limit for Filing Appeal, GN 03101.010

4. Provide SBC Election Statement (SSA-795) to the Individual

A separate election statement (SSA-795) is required at each level of appeal.

The election statement must be specific to the claim type:

  • Title II Benefit Continuation Election Statement

  • Auxiliary Benefit Continuation Election Statement

  • Title XVI and Concurrent Title II/Title XVI - Benefit Continuation Election Statement

  • Extended Period of Eligibility (EPE) Continuation Election Statement

IMPORTANT: In concurrent cases, complete Exhibits 1 and 3, DI 12095.171.

See SSA-795 Election Statement - Exhibits, DI 12095.171 for the exhibits of the specific election statements. In concurrent cases, complete Exhibits 1 and 3.

NOTE: Explain to the individual that the election statement is required whether he/she elects or declines SBC.

5. Provide Appeal Forms to the Individual

  • Appealing the medical cessation (or medical adverse reopening/revision determination) is required for the individual to have the option of SBC. See DI 12027.001A.

  • The appeal forms must be appropriate to the individual’s level of appeal. See DI 12027.010B.2.

6. Assist the Individual in Completing Any Forms if Assistance is Needed or Requested by the Individual

If the individual needs or requests help in completing any forms, assist them to do so.

7. Document the Contact

a. Contact made by telephone or mail - SBC and appeal forms mailed to individual

  • Use the Modernized Supplemental Security Income Claims Systems (MSSICS) and/or Modernized Claims System (MCS) development worksheets to set-up control dates.

  • Set up tickle dates for receipt of the SBC election statement and appeal forms 15 days from the medical cessation notice date.

  • If the case is not active in either MSSICS or MCS, use the Modernized Development Worksheet (MDW).

  • Setting up control and tickle dates documents the individual’s contact with the Social Security Administration (SSA) for protective filing purposes.

b. Contact made by FO visit:

  • Set up the necessary control dates to document the contact when the individual does not complete the SBC election statement and/or appeal forms at this FO visit. Follow DI 12027.010B.7.a.

  • Follow DI 12027.010B.8. through DI 12027.010B.10., when the individual provides the SBC and appeal forms to the FO.

  • See DI 12027.010C. for SBC systems inputs.

8. Individual Declines SBC

  • Place election statement showing that the individual declined SBC in the individual’s official folder. See DI 12027.008B.10.

  • Provide a copy of the signed election statement (SSA-795) to the individual.

9. Individual Elects SBC

  • Place election statement indicating individual elected SBC in the individual’s official folder. (See DI 12027.008B.10.)

  • Provide the individual a copy of the signed election statement (SSA-795).

  • Follow the systems instructions in DI 12027.010C.

10. Folder Documentation

  • Fax the signed election statement (SSA-795) into section E of the electronic folder (EF), if the official folder is electronic. Verify the document is in the EF then shred the original per Paper Retention Timeframes.

  • Place the signed election statement (SSA-795) in the blue section of the modular disability folder (MDF), if the official folder is paper.

C. Procedure - Systems Input for SBC

To streamline medical cessation processing, SSA added functionality to the Electronic Disability Collect System (EDCS). EDCS now automates benefit termination actions, communicates record updates to the disability claim file, and initiates SBC payment and Medicare actions during medical cessation appeals.

1. Cases Involving EDCS

For an explanation of EDCS system inputs for benefit continuation, see DI 81010.255 for reconsideration requests and DI 81010.257 for hearings requests. The Post Entitlement Online System (POS) should not be used to initiate Title II SBC request.

2. EDCS Exclusion Cases

  • SBC request involving a Title II EDCS exclusion are input via the EDCS Exclusion Appeal Screen (EEAI) available via the Disability Claims File. For an explanation of system inputs see, CDR 001.025.

 


DI 12027 TN 1 - Statutory Benefit Continuation (SBC) - 1/26/2019