Effective Dates: 9/30/2024 - Present

Identification Number:
DI 12027 TN 9
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Statutory Benefit Continuation (SBC)
Type:POMS Full 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. 9, 09/30/2024

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

Upon Receipt

Background

The Office of Disability Policy is updating procedures regarding late appeal and statutory benefit continuation (SBC) elections. In response to an OIG audit recommendation, we expanded guidance on the field office and hearing office communication procedures.

Summary of Changes

DI 12027.008 Evaluating the Time Limits for Electing Statutory Benefit Continuation (SBC)

  • •

    Subsection A - minor edits

  • •

    Subsection B - Expanded on procedures for late appeal with SBC elections.

DI 12027.008 Evaluating the Time Limits for Electing Statutory Benefit Continuation

A.  Time limit considerations for statutory benefit continuation (SBC) requests

The individual (or their representative payee) must request SBC for cash benefits and Medicare, if applicable, within 15 calendar days (10 days plus 5 days for mailing) from the date of the medical cessation, adverse reopening medical determination notice, or the unfavorable reconsideration determination notice.

Separate SBC elections are required at the reconsideration and administrative law judge (ALJ) hearing levels. SBC cannot be elected at the Appeals Council (AC) level of review. If the AC remands the case to the ALJ, the individual can receive SBC. See DI 12027.060 for Title II only cases and DI 12027.065 for concurrent Title II/Title XVI cases.

Follow the procedures in DI 12027.010 for obtaining the individual's SBC election as well as the following specified time limits:

  • •

    The individual may change election options only within the 15-day time frame but may request to stop receiving SBC at any time.

  • •

    If, during the 15-day election period, the individual declines SBC, they will not have the opportunity to elect SBC again until the individual receives the reconsideration determination notice and files an appeal at the hearing level.

  • •

    An election remains effective until a new determination or decision on the current appeal is issued, or until the individual asks to stop receiving SBC, whichever is earlier.

  • •

    The 60-day appeal period for requesting reconsideration or an ALJ hearing is not affected by an individual's SBC election.

A request for SBC establishes the claimant's intent to appeal. See DI 12026.020 for field office appeal procedures at the reconsideration level and DI 12010.001 for hearings before an ALJ. See GN 03101.020 about time limits for filing an appeal.

B.  Late election of SBC and good cause

An SBC election is late if it is received more than 15 calendar days (10 days plus 5 days for mailing) from the date of the medical cessation, adverse medical reopening determination notice, or unfavorable reconsideration determination. Accept a late election only if good cause for the late election exists. See DI 12027.001 for procedures on obtaining the SBC election statement. Take the following actions to make a good cause determination:

1. Good cause determination at the reconsideration level

If the field office (FO) receives the SBC election request after the 15-day period at the reconsideration level, develop good cause for the late request and prepare a good cause determination.

  1. a. 

    As indicated in GN 03101.020, consider the reason for the delay using the following criteria:

    • •

      The circumstances that kept the individual from making the request on time.

    • •

      The individual’s physical, mental, educational, or linguistic limitations (including limited English proficiency) prevented the individual from understanding their appeal rights to timely file the request.

    • •

      The actions of the Social Security Administration (SSA) or the Centers for Medicare and Medicaid Services (CMS) misled the individual.

    • •

      The individual did not understand the requirements of the Social Security Act (Act), resulting from amendments to the Act, other legislation, or court decisions.

  2. b. 

    Document your good cause determination on form SSA-553 Special Determination or in the applicable appeals path within the FO claims processing system. Record the reason for the late election, analysis of the facts, and your determination as to whether there is good cause for the late request.

  3. c. 

    For a completed SSA-553, store the form in section B of the electronic folder. For non-electronic cases, upload the form to the Evidence Portal and, file the SSA-553 in the Red-Jurisdictional Documents/Notices section of the modular disability folder (MDF).

  4. d. 

    If you do not find good cause for late filing, prepare the "Good Cause Denial for SBC" notice located in the continuing disability review (CDR) folder in the Document Processing System (DPS), see NL 00703.480.

IMPORTANT: 

In cases where SBC is elected late and we determine good cause exists, reinstate payments as of the first month of non-payment following the disability cessation or adverse reopening determination.

NOTE: 

A finding that good cause does not exist for a late SBC election cannot be appealed.

2. Good cause determination at the hearing level

  1. a. 

    Hearing request with late SBC election

    If the individual files a hearing request within the 60-day appeal period, and the SBC election request after the 15-day election period, the FO determines whether there is good cause for late filing of the SBC election. For more information on good cause determinations, see DI 12027.008B1, in this section, and GN 03101.020D.2.

  2. b. 

    Late hearing and SBC election requests

    If the individual files both the hearing and SBC election requests more than 60 days after receipt of the reconsideration determination notice, the ALJ makes the good cause determination for both the appeal and SBC election request. Take the following steps to notify the hearing office:

    • •

      Select "No" on the SBC field in EDCS.

    • •

      In EDCS, include an SSA-5002 (Report of Contact) documenting receipt of the late appeal and SBC election, instruct the hearing office to make a good cause determination on both the untimely appeal and SBC election, and ask the hearing office to notify the individual of the determination.

    • •

      Transfer the appeal with the SBC election request to the hearing office.

  3. c. 

    ALJ finds good cause

    When the ALJ determines good cause and the late appeal and SBC requests are granted, the hearing office will notify the FO via an assistance request in eView, or by email to the FO email address for paper cases. The FO will reinstate SBC payments and Medicare, if applicable, as of the first month of non-payment following the reconsideration determination. Reinstatement of Title II benefits may require assistance from the Processing Center (PC).


DI 12027 TN 9 - Statutory Benefit Continuation (SBC) - 9/30/2024