Identification Number:
EM-21003 REV 2
Intended Audience:All RCs/ARCs/ADs/FOs/TSCs/PSCs/OCO/OCO-CSTs/OHO/OARO/DDS/OQR
Originating Office:ORDP ODP
Title:Elimination of the Five-month Waiting Period for Disability Insurance Benefits (DIB) Claims Approved Based on Amyotrophic Lateral Sclerosis (ALS) with a Notice of Award date of July 23, 2020 or Later
Type:EM - Emergency Messages
Program:Disability; Medicare
Link To Reference:See Reference at the end of this EM.
 
Retention Date: September 29, 2021

Revision Statement: This EM replaces the version issued on February 8, 2021.

Summary of updates:

We revised this EM to inform technicians and adjudicators of an amendment to the ALS Disability Insurance Access Act of 2019 that revises the eligibility criteria for the exemption of the five-month waiting period.


    A. Purpose

      This EM informs technicians and adjudicators that amyotrophic lateral sclerosis (ALS) based DIB claims with a Notice of Award date on or after July 23, 2020 are no longer subject to the five-month waiting period.

    B. Background

      Currently, and since July 1, 2001, disability beneficiaries diagnosed with ALS do not serve the 24-month Medicare waiting period.

      On December 22, 2020, the ALS Disability Insurance Access Act of 2019 became law (PL 116-250). This law eliminated the 5-month waiting period for DIB awardees with ALS who file a disability claim on or after December 23, 2020.

      On March 23, 2021, the President signed into law a technical amendment to the ALS Disability Insurance Access Act of 2019 (Pub. L. 117-3). The amendment makes the elimination of the 5-month waiting period applicable to DIB claims based on ALS that we approved on or after July 23, 2020. For purposes of applying this provision, we consider the date of the Notice of Award to be the date on which we approved the claim.

      ALS is a motor neuron disorder that rapidly and progressively attacks the nerve cells responsible for controlling voluntary muscles. Regardless of the part of the body first affected by the disease, muscle weakness and atrophy spread to other parts of the body as the disease progresses. There is no known cure for ALS.

      ALS is a compassionate allowance (CAL) condition and the Electronic Disability Collect System (EDCS) identifies the case as a CAL condition when ALS is listed as the alleged disabling condition. Expedited processing applies to all CAL cases.


    C. Addressing public inquiries

      If you receive an inquiry regarding the new law, explain that the elimination of the 5-month waiting period applies to claims approved based on ALS with a Notice of Award date of July 23, 2020 or later. Assure the individual that we are tracking these cases for processing in accordance with the law.


    D. Disability claims approved on or after July 23, 2020

      A cadre of employees at the Northeastern Program Service Center (PSC 1) will review adjudicated DIB cases based on ALS with a Notice of Award dated on or after July 23, 2020 and process amended awards, as needed, to correct the date of entitlement for DIB benefits.


    E. Whether or not additional benefits are due as a result of the law’s amendment will depend on individual circumstances. Below are two examples:

      1. William filed for DIB benefits on June 14, 2020 and received a Notice of Award dated August 2, 2020 based on ALS with an established onset date of February 20, 2020. Under the new law, William will be due benefits from March through July 2020. William does not need to contact the Social Security Administration (SSA) to correct this. Because the amended effective date under the law eliminates the waiting period we previously applied to William’s claim, PSC 1 will process the amended award.

      2. Sue filed for DIB benefits on January 12, 2021 and received a Notice of Award dated March 11, 2021 based on ALS with an established onset date of May 1, 2019. Sue received the maximum 12-months of retroactive benefits from the application filing date, making January 2020 Sue’s month of entitlement. There are no additional months of retroactive benefits due as a result of the new law because Sue has received the maximum benefits payable.


    F. New DIB claim based on ALS

      When taking a claim where the claimant alleges ALS as the disabling condition, the technician should:

        · Add an issue in the Modernized Claims System (MCS) to the DW01 screen of “ALS CASE” with a tickle date matching the Disability Determination Services (DDS) Decision tickle date and “No 5-mo wait period” in the remarks.

        · Add the ALS flag following existing policy when transferring a case to the DDS or the Office of Hearings Operations (OHO).

        · Do not process these cases as a non-medical completion (SPORT).


    G. Field office (FO) handling requests to withdraw (WD) a claim

      You may receive WD inquiries from claimants awarded DIB benefits based on ALS prior to July 23, 2020 who seek to file a new claim that meets the criteria for the elimination of the 5-month waiting period. In discussing the request, explain how the 12-month maximum retroactivity will affect the new DIB claim based on the new filing date. Follow GN 00206.001 to provide additional WD information. Each claimant must consider his or her own personal factors and situation to determine if withdrawing the claim and filing a new claim is the best option. Do not make the decision for the claimant. If the claimant decides to WD his or her claim, follow the instructions below:


        · Discuss the effect the WD has on Medicare coverage and Supplemental Security Income (SSI) benefits (if applicable) and follow current procedures listed in GN 00206.001.
        · Secure a WD request from the number holder and auxiliaries (if applicable) – During the Coronavirus Disease 2019 (COVID-19) pandemic, obtain the WD request by telephone and record it on the SSA-521. Document on the SSA-521 that the beneficiary’s verbal request to WD his or her disability claim is related to the new law for ALS beneficiaries and will file a new disability claim.
        · Upload the SSA-521 into eView (NDRed for paper disability folders) and email the SSA-521 to PSC 1 for action.
        · On the Subject line indicate, “ALS WD case-high priority.”
        · Suspend DIB benefits and add the following message to the Master Beneficiary Record (MBR), “ALS withdrawal requested.”
        · To assist ALS claimants during the COVID-19 pandemic, the claimant can file a new DIB claim with his or her withdrawal request.
        · When receipting in the new claim, establish an issue of “ALS” on the DW01, receipt with the new filing date, and add “new claim after WD” in the remarks.
        · To account for the repayment of benefits from the prior claim, document the new claim with the following claimant statement on the application: “I acknowledge that the agency will offset any benefits that I previously received against benefits awarded based on this application. I also acknowledge that I will be responsible to repay benefits received from the prior application if the new application is not approved.”
      · If the new claim does not allow for additional benefits due to the maximum 12-month retroactivity, the PSC will follow GN 00206.014B to calculate and request repayment of benefits.
      H. New disability claim filed with or after a withdrawal request

        If the beneficiary decides to withdraw his or her claim and file a new DIB claim with ALS as the disabling condition the following applies:

        1. FO


          · The filing date of the new claim is the date we receive the application. We can also use the date we received the WD request as protective filing, if the claimant indicated his or her intent to file a new claim.

          · When routing the new claim to DDS for a determination, include an SSA-5002 with the following remark, “Prior DIB claim withdrawn, new claim filed to be eligible for the five-month waiting period exemption of ALS beneficiaries. Please review evidence obtained in prior claim in making a determination for this claim.”


        2. DDS

          In addition to any new evidence, use the evidence in the prior claim to make a determination on the current claim.

    Direct all program-related and technical questions to your Regional Office (RO) support staff or Program Service Center (PSC) Operations Analysis (OA) staff. RO support staff or PSC OA staff may refer questions, concerns or problems to their Central Office contacts.

    References:

    DI 11005.604 Processing Compassionate Allowances (CAL) in the Field Office (FO)
    DI 11036.001 Amyotrophic Lateral Sclerosis (ALS) - Medicare Waiting Period Waived- Field Office (FO)
    DI 23022.100 Amyotrophic Lateral Sclerosis (ALS)
    DI 23580.001 Amyotrophic Lateral Sclerosis (ALS)-Medicare Waiting Period Waived-Disability Determination Services (DDS)
    GN 00206.001 Withdrawal (WD) of a Title II Benefit Application
    GN 00206.005 Requirements for Withdrawal (WD) of a Benefit Application
    GN 00206.011 Processing Withdrawal (WD) Requests before Adjudication
    GN 01010.400 Claim Denials
    GN 00204.030 Retroactivity for Title II Benefits


    EM-21003 REV 2 - Elimination of the Five-month Waiting Period for Disability Insurance Benefits (DIB) Claims Approved Based on Amyotrophic Lateral Sclerosis (ALS) with a Notice of Award date of July 23, 2020 or Later - 03/29/2021