Identification Number:
DI 29025 TN 4
Intended Audience:See Transmittal Sheet
Originating Office:ODP
Title:Preparation of Continuing Review Cases and Reopenings Applicable toDisability Hearings (Pre-DHU Processing)
Type:POMS Transmittals
Program:
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 290 – Reconsideration of Continuing Disability Review (CDR) Cases, and Reopenings Applicable to Disability Hearings (Pre-DHU Processing)
Subchapter 25 – Preparation of Continuing Review Cases and Reopenings Applicable toDisability Hearings (Pre-DHU Processing)
Transmittal No. 4, 05/23/2022

Audience

PSC: DE, DEC, RECONR, SCPS;
OCO-OEIO: CR, ERE, FDE, RECONE;
OCO-ODO: DE, DEC, DS, PETE, PETL, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

ODP

Effective Date

Upon Receipt

Background

This transmittal is a part of an ongoing rewrite of the program operations manual system (POMS) sections related to disability processing at the pre-hearing (PH) level. We are adding new sections to DI 29025 that provide instructions on how to process a case at the PH level when the recipient attains age 18 during the continuing disability review (CDR) reconsideration process.

Summary of Changes

DI 29025.007 Processing Title XVI Childhood Continuing Disability Review (CDR) Reconsideration Cases Involving Attainment of Age 18 at the Pre-hearing (PH) level

This new section provides instructions for the PH level on how to process a case when the recipient attains age 18 during the CDR reconsideration process.

 

DI 29025.008 Notice of Title XVI Childhood Continuing Disability Review (CDR) Reconsideration Involving Age 18 Redetermination - Exhibit

This new section provides sample notice language for when the recipient attains age 18 during the CDR reconsideration process.

DI 29025.007 Processing Title XVI Childhood Continuing Disability Review (CDR) Reconsideration Cases Involving Attainment of Age 18 at the Pre-hearing (PH) Level

A. Statutory and regulatory background

When we review a determination that disability has medically ceased, we consider the recipient's disability through the date of the current determination. We determine whether the recipient was or has again become disabled at any point through the current date. Social Security Act, Sec. 1614(a)(4); SSR 13-3p

Pursuant to Public Law (P.L.) 104-193, all title XVI childhood disability recipients who attained age 18 on or after August 22, 1996, and were eligible as children in the month before the month in which they attained age 18, must have their eligibility redetermined under the adult standards for initial claims. We are required to notify the recipient in writing prior to completing the disability redetermination. 20 CFR 416.987(d)

B. Policy overview

1. Applicable standard

When the recipient attains age 18 during a childhood CDR reconsideration, the PH reviewer must use different standards for disability evaluation that are dependent on the recipient's age throughout the review period. The PH reviewer will use:

  • the childhood medical improvement review standard (MIRS) (DI 28005.020) to evaluate the period prior to the attainment of age 18, and

  • the adult disability standards upon attainment of age 18, to evaluate the period after attainment of age 18 (DI 23570.020B).

2. Assessment forms

The PH reviewer ensures the following assessment forms are completed:

  • SSA-538 Childhood Disability Evaluation Form or disability determination explanation (DDE) to assess disability under childhood MIRS, AND

  • SSA-4734-BK Physical Residual Functional Capacity Assessment, SSA-416 Medical Evaluation, SSA-4734-F4-SUP Mental Residual Functional Capacity Assessment, or SSA-2506-BK Psychiatric Review Technique, as appropriate, to assess disability under the adult rules.

The case must clearly reflect the assessment under the childhood and the adult rules. An unfavorable or partially favorable determination will be reviewed in the disability hearing unit (DHU) and upon higher levels of appeals, whereas a fully favorable determination will become the comparison point decision (CPD) folder for the next CDR.

3. General conclusions

Generally, there are two basic conclusions at the PH level:

a. Fully favorable determination

Consider a case fully favorable when the entire period evaluated within the reconsideration timeframe is favorable. When a recipient attains age 18 or is within 2 months of attaining age 18, both the childhood assessment and the adult assessment must be favorable for the case to be considered fully favorable.

When a fully favorable determination is supported, the PH reviewer will follow the instructions in DI 29025.007C in this section and issue the determination.

b. Less than favorable determination

Consider a case less than fully favorable if any portion within the reconsideration timeframe is unfavorable. When a recipient attains age 18 or is within 2 months of attaining age 18, if either the childhood assessment or the adult assessment is unfavorable then the conclusion is less than favorable.

When a less than fully favorable determination is supported, the PH reviewer will follow DI 29025.007D in this section and forward the case to the DHU.

C. Steps when the evidence supports a fully favorable determination and an evaluation under the adult rules applies

The PH reviewer will complete the following actions when the evidence supports a fully favorable determination and the recipient is at least 17 years and 10 months of age:

  1. 1. 

    Send a notice to the recipient to notify him or her that the case will be evaluated under the adult rules for the period after attainment of age 18. The notice should be sent prior to the date of the determination. See DI 29025.008 for an example of the notice.

  2. 2. 

    Ensure the appropriate assessment forms are complete. See DI 29025.007B2. in this section.

  3. 3. 

    Use age 18 redetermination continuance codes. See DI 28084.020C5.

  4. 4. 

    On the SSA-832 Cessation or Continuance of Disability or Blindness Determination and Transmittal-Title XVI, include the remarks "P.L. 104-193" and "Period starting with attainment of age 18 adjudicated under adult rules." (In the case of a fully favorable determination, this will allow the field office (FO) to screen out an age 18 redetermination.)

  5. 5. 

    Do not make an adult determination on the case until the recipient attains age 18.

  6. 6. 

    Unless otherwise indicated above, follow normal procedures for the form completion and adjudication. See DI 29005.005C.

NOTE: We consider a case fully favorable when all assessments through the date of determination direct a continuance. If any portion of the assessment period through the date of the reconsideration determination is unfavorable, follow instructions in subsection DI 29025.007D in this section.

D. Steps when the evidence supports a less than fully favorable determination

Follow the guidelines in DI 29025.001 and prepare the case for the disability hearing.

NOTE: We consider a case less than fully favorable when any period under assessment is unfavorable. That is, either the childhood MIRS or the adult rules assessment results in an unfavorable determination.

 

DI 29025.008 Notice of Title XVI Childhood Continuing Disability Review (CDR) Reconsideration Involving Age 18 Redetermination - Exhibit

Social Security Administration

Supplemental Security Income

Important Information

Date: _______________

[Claim Number or BIN]

 

John Payee for

Jane G. Beneficiary

101 Main Street

My City, ST 00001

 

This letter is about your SSI. You do not need to call us.

Earlier you asked that we reconsider our decision that you were no longer disabled. We are writing now to tell you that because you are over age 18 or soon to turn age 18, we will use the same disability rules we use for adults who file new claims to decide your case for the period after you turned age 18. However, we will not apply the rule that says we must deny your claim if you are working.

At any time during the reconsideration process, if you think of new information which might be important, such as a visit to a doctor or a hospital, let us know right away.

 

We Will Let You Know What We Decide

Trained staff who had no part in making the original decision that you aren’t disabled will decide if you are disabled. The disability rules for adults are different than the disability rules for children. We will evaluate the period prior to age 18 under the child rules and we will evaluate the period after age 18 under the adult rules.

When we decide we will let you know our decision. Our letter will explain your right to appeal the decision. If you appeal the decision you can also choose to have us continue to make payments until we decide the appeal.

See Next Page

Page 2 of 2

[Claim number or BIN]

Information About Work

If you work or want to work but are concerned about losing your SSI or medical assistance, your local Social Security office can tell you more about work incentives and how work and earnings can affect your SSI.

 

If You Have Any Questions

We invite you to visit our website at www.ssa.gov to find general information about Social Security. If you have any questions, you may call us toll free at 1-800-772-1213, 8 a.m. to 7 p.m., Monday through Friday. You may also call if you are deaf or hard of hearing, call TTY 1-800-325-0778. We can answer most of your questions over the phone. Our busiest times are the first week of the month and Mondays. We may be able to handle your call more quickly if you can call us at other times.

You can write or visit any Social Security office. The address of the office that serves your area is:

123 Main Street

Anywhere, USA 00000

If you call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly.

Social Security Administration

 


DI 29025 TN 4 - Preparation of Continuing Review Cases and Reopenings Applicable toDisability Hearings (Pre-DHU Processing) - 5/24/2022