Identification Number:
DI 13006 BASIC
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Title XVI Age 18 Medical Redeterminations
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 130 – Continuing Disability
Subchapter 06 – Title XVI Age 18 Medical Redeterminations
Transmittal No. BASIC, 10/13/2021

Audience

FO/TSC: CS TXVI, CS, CS TII, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;
ODD-DDS: REF;
OCO-ODO: BET, BTE, CR, CST, CTE, CTE TE, DE, DEC, DS, PAS, PETE, PETL, RCOVTA, RECONE, RECOVR;
OCO-OEIO: BET, CR, CTE, ERE, FCR, FDE, FDEC, RECONR, RECONE, RECOVR;
PSC: CA, CS, DE, DEC, DTE, ICDS, IES, ISRA, RECONR, SCPS, TSA, TST;

Originating Component

ODP

Effective Date

Upon Receipt

Background

This transmittal contains a new POMS subchapter DI 13006.000. This new subchapter contains some of the instructions from POMS DI 11070.000, which we archived. This subchapter provides instructions that the field offices (FOs) will follow when completing the continuing disability review (CDR) cases for children under age 18 and when completing an age-18 redetermination.

Summary of Changes

DI 13006.005 Requirements for an Age-18 Redetermination

This section complies with our plain language guidelines and includes cross-references to instructions, where appropriate. This section includes information from DI 11070.001, which will become obsolete.

DI 13006.010 Field Office (FO) Actions to Identify Age-18 Redetermination Cases

This section complies with our plain language guidelines and includes cross-references to instructions, where appropriate. This section includes some of the information from DI 11070.010, which will become obsolete.

DI 13006.020 Field Office (FO) Actions to Screen and Process an Alert for an Age-18 Redetermination Case

This section complies with our plain language guidelines and includes cross-references to instructions, where appropriate. This section includes information from DI 11070.030, which will become obsolete.

DI 13006.025 Field Office (FO) Procedures for Processing an Age-18 Redetermination

This section complies with our plain language guidelines and includes cross-references to instructions, where appropriate. This section includes some of the information from DI 11070.010, which will become obsolete.

DI 13006.030 Field Office (FO) Procedures After the Disability Determination Services (DDS) Makes a Determination on an Age-18 Redetermination Case

This section complies with our plain language guidelines and includes cross-references to instructions, where appropriate. This section includes information from DI 11070.040, which will become obsolete.

DI 13006.035 Field Office (FO) Procedures When Appealing an Age-18 Redetermination

This section complies with our plain language guidelines and includes cross-references to instructions, where appropriate.

DI 13006.100 Exhibit Notice to Initiate an Age-18 Redetermination

The content in this section contains information from DI 11070.105.

DI 13006.105 Exhibit of an Age-18 Redetermination Disability Control File Query (DCF)

This section contains information form DI 11070.115.

Conversion Table
Old POMS ReferenceNew POMS Reference
DI 11070.010DI 13006.010
DI 11070.030DI 13006.020
DI 13006.010DI 13006.025
DI 13006.040DI 13006.030
DI 13006.035
DI 11070.105DI 13006.100
DI 11070.115DI 13006.115

DI 13006.005 Requirements for an Age-18 Redetermination

A. Statutory requirement for an age-18 redetermination

Under Section 1614(a)(3)(H)(iii) of the Social Security Act, we must redetermine the eligibility of individuals who were eligible for Supplemental Security Income (SSI) based on disability in the month before the month in which they attained age 18. This redetermination generally occurs during the one-year period beginning on the individual’s 18th birthday. The age-18 redetermination uses the rules for determining initial eligibility for adults. The medical improvement review standard (MIRS) used in a continuing disability review (CDR) does not apply to an age-18 redetermination.

B. Who is subject to an age-18 redetermination?

The requirement for an age-18 redetermination applies to anyone who attains age 18 on or after August 22, 1996 and received SSI benefits as a disabled child. For additional information on the policy for attainment of age, see GN 00302.400.

C. When do we process an age-18 redetermination?

The law requires us to conduct a disability redetermination within one year of the SSI recipient's 18th birthday or, in lieu of a CDR, whenever we determine that an age-18 redetermination was required and had not been initiated.

The field office (FO) must make every effort to initiate an age-18 redetermination:

  • prior to the recipient’s attainment of age 19; or

  • later if an age-18 redetermination was not performed prior to the recipient’s attainment of age 19.

For additional information on processing an age 18 medical redetermination, see DI 13006.025.

NOTE: Prior to the FO sending an age 18 case to the Disability Determination Services (DDS), the FO must ensure the change of disabled child (DC) to disabled individual (DI) status on the SSI record, see DI 13006.010A4. To create a record in the Electronic Disability Collect System (EDCS) for an age-18 determination, see DI 81010.232.

DI 13006.010 Field Office (FO) Actions to Identify Age-18 Redetermination Cases

A. Identifying cases that require an age-18 redetermination

The FO should use the procedures below to review and identify cases that require an age-18 redetermination.

1. Disability Control File (DCF)

The Office of Systems loads age-18 redetermination cases into the DCF and create a continuing disability review (CDR) alert, see MSOM CDR 001.001. The cases will appear on the jurisdictional FO’s pending medical CDR list.

2. Stars and Stripes the Next Generation (SSTNG)

The FOs can identify recipients that require an age-18 redetermination using the SSTNG website. For example, if a recipient is in SSTNG for an age-18 critical birthday redetermination (RZ), the FO will need to conduct the age-18 redetermination interview at the same time as the RZ interview. For additional information on RZs, see SI 02305.016.

3. Supplemental Security Record (SSR)

The FOs can determine when a recipient is due for an age-18 redetermination by reviewing the Diary Screen (DIAR) segment of the Supplemental Security Record (SSR) query for an attainment of age 18 (KB) diary, see SI 02309.003.

NOTE: A case is eligible for selection as an age-18 redetermination no earlier than two months prior to attaining age 18.

4. Review the claim folder

Review the claim folder to determine if Disability Determination Services (DDS) or the Office of Hearings Operations (OHO) made a medical determination or decision using the adult sequential evaluation after the recipient attained age 18. Usually, the date of the favorable disability DDS determination is an appropriate indicator if:

  • the date of the DDS determination is before the date the person attained age 18, assume the DDS did not apply the adult criteria; or

  • the DDS determination was on or after the date the person attained age 18, review the Remarks section on the form SSA-831, see DI 26510.095.

In addition, the Type of Master Record (TMR) data on an SSR query reply should reflect the change from disabled child (DC) child to disabled adult (DI) adult status (For example, “TMR:DC, DI-mm/yy,” where mm/yy are the month and year following the month and year in which the individual attained age 18), see DI 81010.232. If the FO is uncertain whether the DDS applied the adult criteria, the FO should contact the regional office (RO) disability coordinator, see DI 13005.020I.3.

B. Current actions for using the DCF and SSTNG system

The FO must review or complete the following actions in the DCF or SSTNG system.

1. Review the DCF:

  • Age 18 cases in the DCF reflect as a Type 4 CDR (LBW/CHLD/18), with the category legend of “age 18/DDS”, and an event legend of “direct release”.

  • The DCF may occasionally contain cases that do not to meet the non-medical criteria for a disability redetermination. FOs should select Event 5 (SSR/MBR condition) and apply the current screen-out criteria with the exception “...a fully developed CDR by the DDS/ALJ done within the last 12 months.” For additional information on the age-18 redetermination screen out criteria, see DI 13005.020.

2. Complete the following actions for the SSTNG system:

  • The FO must coordinate processing the age-18 redetermination and RZ on the SSTNG website together. If the recipient is on SSTNG for an RZ redetermination, FOs must conduct the age-18 redetermination interview at the same time.

  • All cases, in which a “KB” diary is present due to attainment of age, requires a medical redetermination by the DDS.

    NOTE: If the SSI recipient receives an allowance for disability prior to attaining age 18, The FO and DDS must still complete the age-18 redetermination.

DI 13006.020 Field Office (FO) Actions to Screen and Process an Alert for an Age-18 Redetermination Case

When the FO processes an age-18 redetermination, the FO must follow the guidelines in DI 13005.020A-D. When the FO is determining whether to screen out an age-18 redetermination, follow the instructions below.

A. Screening out a Title XVI age-18 redetermination

Screen out a Title XVI age-18 redetermination if:

  1. 1. 

    The claim is pending a request to withdraw or has been withdrawn.

  2. 2. 

    There was a prior cessation and termination determination, but no action occurred to terminate the case, see DI 13015.265.

  3. 3. 

    The recipient was not in PSY C__, E__, or M__ on the Supplemental Security Record (SSR) in the month before the month the person attained age 18 and is expected to remain in a non-payment status for 12 months. Do not screen out a Section 1619 case, which may be in payment status N01, see DI 13005.016. For additional instructions on processing cases in suspense payment status, see DI 13005.020E; or

  4. 4. 

    Review of the claim folder (paper or electronic) shows that a disability determination using the adult sequential evaluation of disability for initial claims was done after the recipient attained age 18, see DI 13006.010A4.

B. Coordination of workloads

Before a recipient attains age 18, the Supplemental Security Income (SSI) policy requires completion of a non-medical redetermination (RZ) that includes living arrangements, income, and resource issues. For additional instructions on critical birthday diaries, see SI 02309.001. When possible, the FO should coordinate the RZ interview and age-18 redetermination. This means that the FO should conduct the age-18 disability redetermination when the RZ interview is due. The Type of Master Record (TMR) must be changed from disabled child (DC) to a disabled individual (DI) in order to establish the age-18 redetermination in the Electronic Disability Collect System (EDCS), see DI 81010.232. For additional details on processing an age-18 redetermination, see DI 13006.025.

DI 13006.025 Field Office (FO) Procedures for Processing an Age-18 Redetermination

A. Identifying an age-18 redetermination

The FO must use the following requirements below when identifying an age-18 redetermination.

1. Requirements for an age-18 redetermination

When possible, the FO must time the interview to coordinate the age-18 redetermination and non-medical redetermination (RZ) interviews, so that the Disability Determination Services (DDS) will receive the case on or after the date that the disabled individual attains age 18. In some cases forwarded to the DDS, the DDS may determine that an age-18 redetermination is required instead of a continuing disability review (CDR). These cases will be disabled individuals who were first eligible as children who have attained age 18, and had never been subject to an age-18 redetermination or equivalent as determined by the DDS after attaining age 18. For additional information on cases identified as an age-18 determinations in the DDS, see DI 23570.010B.1.b.

NOTE: The DDS will determine whether to apply the adult criteria to a case. However, if the FO recognizes that a disabled individual should have been subject to an age-18 redetermination, the FO may initiate the age-18 redetermination.

2. Review the disability control file (DCF)

If the Category field of the CDR query screen displays “Age 18/DDS”, initiate the age-18 redetermination, see MS 00501.004.

B. Processing an age-18 redetermination

The FO must complete the following procedures below when processing an age-18 redetermination.

1. Initiate and process the age-18 redetermination

The age of the disabled individual at the time of the FO initiation affects the processing of the case. The FO should not initiate a case prior to the month before the month the disabled individual attains age 18. A case is eligible for selection as an age-18 redetermination no earlier than two months prior to attaining age 18.

Complete the following procedures:

  1. a. 

    Check the age of the disabled individual before sending the “Notice of Disability Redetermination.” Notices sent using the workload action center (WAC) should be stored in the online retrieval system (ORS).

  2. b. 

    Send the “Age 18 Notice of Disability Redetermination” to the Title XVI disabled individual and his or her representative payee, see DI 13006.100.

    NOTE: If the case is concurrent (but the Title II CDR diary has not matured) advise the disabled individual and his or her representative payee that an unfavorable determination on the disability redetermination may trigger a CDR on the Title II case.

  3. c. 

    Document the folder with a copy of the “Age 18 Notice of Disability Redetermination.”

  4. d. 

    Update the transfer date on the CDR FO Input (IFOA) screen of the DCF to record the date the FO sends the “Age 18 Notice of Disability Redetermination.”

  5. e. 

    Update the DCF by entering through the IFOA screen Item #6 (transfer direct release CDR). Show your FO Code as the “Office Responsible.” The DCF will automatically assign the date of input.

NOTE: If the FO is unable to locate the prior medical folder, see DI 13015.080.

2. Conduct the age-18 redetermination

The FO must complete the following when conducting the age-18 redetermination interview:

  1. a. 

    Conduct the interview according to DI 11005.001. Do not take a new application.

    • Sections 1619(a) and (b) of the Social Security Act apply to these cases, see SI 02302.000. The initial claim procedure concerning substantial gainful activity (SGA) denials does not apply to an age-18 redetermination.

    • Complete the appropriate initial disability interview forms including:

      1. 1. 

        Form SSA-3367- (Disability Report-Field Office),

      2. 2. 

        Form SSA-3368-BK (Disability Report-Adult); and

      3. 3. 

        Form SSA-827 (Authorization for Source to Release Information to the Social Security Administration).

        NOTE: The Type of Master Record (TMR) must be changed from disabled child (DC) to a disabled individual (DI) in order to establish the age-18 CDR in the Electronic Disability Collect System (EDCS), see DI 81010.232.

    • Obtain the names and addresses of the medical sources and functional information for the year preceding the date of the interview.

    • Ask the disabled individual if he or she is participating in an individualized education program (IEP) or receiving vocational rehabilitation (VR), employment, training, educational, or other support services from any source. In the event the individual is determined to not be disabled under the adult criteria, participation in these types of programs may make the individual eligible for benefit continuation under Section 301 see DI 14510.000.

  2. b. 

    For a case involving a paper folder, add a Disability Redetermination Flag; see DI 11070.110. Check the age 18 line. In concurrent entitlement situations, annotate the flag with the remark “concurrent claim” and attach the Title II folder.

  3. c. 

    Update the IFOA on the DCF to show the transfer of the folder to the DDS, see MSOM Chapter 005. Also, enter any pertinent remarks under the “Remarks” section of the DCF.

  4. d. 

    Ensure the TMR on the SSR changes from a child (DC) to an adult (DI) on the Simulated SSI Record (SSR).

  5. e. 

    Forward the paper folder or electronic folder to the DDS. If the FO is unable to locate the prior paper folder, see DI 13015.080.

    NOTE: Do not establish an age-18 redetermination in EDCS until the TMR is a DI. If the FO already changed the TMR from a child to an adult, it is not necessary to complete a new RZ unless a diary is due. To initiate the age-18 redetermination in EDCS, see DI 81010.232. For electronic CDR exclusions, see DI 81010.210.

DI 13006.030 Field Office (FO) Procedures after the Disability Determination Services (DDS) Makes A Determination on an Age-18 Redetermination Case

The DDS must process a case that attains age 18 using the initial standards for adults, but use the same forms (for example, the form SSA-832) and systems for processing as they do for a continuing disability review (CDR).

A. Fully favorable determinations

The DDS will process fully favorable determinations in the same manner as CDR continuances. The DDS will only return folders to the FO if there are any unresolved non-disability issues. If the case involves paper folder(s), the DDS will forward the folder to the National Records Center (SSANRC) following usual procedures.

B. Unfavorable determinations and cessation dates

Disability ceases as of the date of the age-18 redetermination decision. Eligibility ends the last day of the second month following the month of cessation. During the period between the month of cessation and the last month of payment, the disabled individual must otherwise be eligible for benefits. Non-disability actions (for example, income and resource changes, etc.) are still appropriate.

NOTE: If the case involves a DDS failure to cooperate (FTC) or whereabouts unknown (WU) determination, see DI 28075.005.

C. Procedures for unfavorable determinations

Use the following procedures to process an age-18 determination based on the case type.

1. Age-18 redetermination cases

When the case returns from the DDS or the Office of Disability Operations (ODO), follow normal processing procedures for processing cessations in CDR cases. For cases involving participation in a vocational rehabilitation (VR) or similar programs see DI 14510.003.

2. Concurrent cases

If the DDS examiner, the disability hearing officer (DHO) or administrative law judge (ALJ) did not address the need of a Title II CDR, the FO will initiate a CDR or consider an adverse reopening of the Title II determination whenever there is an unfavorable action on an age-18 redetermination. Normally, the DDS, DHO, or ALJ will address this issue. The FO will not delay implementation of the Title XVI determination due to pending action on the Title II CDR issue.

The standard for continuing disability is different from the standard applied during an age-18 redetermination. It is not unlikely that disability will cease on the Title XVI case while disability is continued under Title II. Once eligibility continues based on an age-18 redetermination, treat the case, for all purposes, as an adult disabled individual (DI) claim. An age-18 redetermination cessation will act as a permanent bar to the cross title adoption of any favorable determination that pre-dates the cessation action.

NOTE: The DDS must never adopt a pre-age 18 determination to a Title II claim.

DI 13006.035 Field Office (FO) Procedures When Appealing an Age-18 Redetermination

The FO must use the following procedures below when appealing an age-18 redetermination.

A. An age-18 redetermination appeal

Any individual dissatisfied with the age-18 redetermination decision can file an appeal following the normal continuing disability review (CDR) procedures. The individual will be eligible for statutory benefit continuation (SBC) through the administrative law judge (ALJ) level of appeals.

B. SBC

Always offer SBC and obtain a signed Form SSA-795 (Statement of Claimant or Other Person) regarding the election to continue or refuse benefits if the disabled individual or representative payee files an appeal within 10 days of receipt of the notice. Always discuss good cause if the disabled individual or representative payee files after the 10 day period, even if the disabled individual or representative payee does not inquire or declines the election of the SBC, see DI 12027.010.

NOTE: Never attempt to dissuade a disabled individual or representative payee from filing an appeal or electing SBC.

DI 13006.100 Exhibit Notice to Initiate an Age-18 Redetermination

Social Security Administration

Supplemental Security Income

Notice of Disability Redetermination

 

Street Address:

City, State, ZIP Code:

Phone:

Office Hours:

Date:

Claim Number: XXX-XX-XXXX

 

Jane G. Beneficiary

101 Main Street

My City, ST 00001

 

Important Notice - You must contact us or your SSI may stop.

We must review the cases of people getting Supplemental Security Income (SSI) payments based on childhood disability after they become age 18. We are writing to let you know that we are starting to review your SSI disability case to decide if you are disabled under the disability rules for adults.

What You Need To Do

Choice 1

Please call us and ask for _____________ .

Choice 2

We would like you to come to our office on ______________ .

When you come in, please ask for _____________ .

If you cannot come in on the date shown or would prefer to talk with us by telephone, please call us as soon as possible.

The office address, telephone number, and office hours are shown above.

If We Do Not Hear From You

We may stop your SSI if you do not answer this letter by Month/Day/ Year or contact us by this date to tell us why we haven't heard from you. Before we stop your SSI, we will send you another letter to explain our decision. The letter will also explain your right to appeal the decision and how to continue getting benefits during the appeal.

Information About Medical Assistance

If your SSI payments stop, any medical assistance you have that is based on SSI may also stop. If this happens, your medical assistance agency should contact you.

The Information We Will Need

When you come in or call, please try to have all of the following things with you. Even if you do not have everything, you still must call us or come in. We will help you get anything you do not have.

  • This letter.

  • The enclosed form(s). Please be sure to complete as much of the form(s) as you can before you come in or call.

  • The names of any medicines you use.

  • Any other information that shows your condition, such as information about:

    • hospital stays and/or surgeries, including the dates and reasons;

    • visits to doctors and/or clinics, including the dates and reasons;

    • work activity;

    • counseling and/or therapy;

    • schools and/or special classes or tutoring; and

    • teachers and/or counselors who have knowledge of your condition.

      We may ask for further information later.

 

We Will Let You Know What We Decide

Doctors and other trained staff will decide if you are disabled. When we decide your case we will use the same disability rules we use for adults who file new claims. However, we will not apply the rule that says we must deny your claim if you are working.

We may decide that you are not disabled under the disability rules for adults and your SSI payments could stop. The disability rules for adults are different than the disability rules for children we used when we last looked at your case. So we may find you are not disabled now even though we found you disabled before.

How Your Benefits May Continue If We Find You Are Not Disabled

If we find that you do not have a disability under our rules for adults, your SSI benefits will usually stop.

However, your benefits may continue while you are:

  • Attending school under an individualized education program (IEP), or

  • Taking part in certain vocational rehabilitation or similar programs.

To qualify, you must be participating in the program before the month your disability ends under our rules. Your SSI benefits could continue until you finish school or complete the program. Be sure to tell us about any program you take part in when you contact us to give us the information we need. We may ask for more information later. You must tell us when you finish school or complete the program. If you get too much SSI money because you do not tell us right away, you must pay back the money. When we decide, we will write and let you know our decision. Our letter will tell you whether you are disabled under the disability rules for adults. Our letter also will explain your right to appeal the decision. If you appeal the decision you can also choose to have us continue to pay benefits until we decide the appeal.

Information About Work

There are special rules that help people with disabilities return to work without losing their SSI benefits and Medicaid. You must follow these rules and report your earnings, or you may have to repay a large part of your benefits. When you report your earnings, we will give you a receipt to verify your report. Keep this receipt with your other important papers from us. For more information on how work may affect your benefits and our work incentive programs, please request our free publication.

  • “Working While Disabled—How We Can Help” (Publication No. 05-10095)

  • “The Red Book,” a guide to our employment support programs.

    You can get these publications online at www.socialsecurity.gov/pubs/EN-05-10095.pdf and www.socialsecurity.gov/redbook. They also include information about the Ticket to Work program, which can help you work or increase your earnings. To learn more, call 1-866-968-7842 (TTY 1-866-833-2967) or visit www.socialsecurity.gov/work.

    Suspect Social Security Fraud?

    Please visit http://oig.ssa.gov/report or call the Inspector General’s Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

    If You Have Any Questions

    We will be glad to answer any questions that you have. Whether we talk to you by phone or in person, you can have a lawyer, friend, or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. Our office has a list of groups that can help you. If you get someone to help you, you should let us know.

    Remember, if you cannot come in or would prefer to talk to us by phone, please call us right away. Our telephone number is shown on the first page of this letter.

    Field Office Manager

    Enclosure(s)

    [The enclosures may include any of the following:

    Form Number SSA-3368 - Disability Report - Adult

    Form Number SSA-827 - Authorization for Source to Release

    Information to the Social Security Administration]

DI 13006.105 Exhibit of an Age-18 Redetermination Disability Control File Query (DCF)

The exhibit in this section is located in MS 00501.004C.


DI 13006 BASIC - Title XVI Age 18 Medical Redeterminations - 10/13/2021