Identification Number:
DI 11080 TN 3
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Consolidated Omnibus Budget Reconciliation Act (COBRA)
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 110 – Initial Claims Processing
Subchapter 80 – Consolidated Omnibus Budget Reconciliation Act (COBRA)
Transmittal No. 3, 10/18/2019

Audience

PSC: CA, CS, DE, DEC, DTE, ICDS, IES, ILPDS, ISRA, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, BIES, BTE, CR, CTE, ERE, FCR, FDE, PETL, RECONE, RECONR;
OCO-ODO: BET, BTE, CR, CST, CTE, CTE TET, DE, DEC, DS, PAS, 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;

Originating Component

ODP

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.

Summary of Changes

DI 11080.010 Philadelphia Disability Processing Unit (PH-DPU) and Disability Determination Services (DDS) Processing Instructions for Consolidated Omnibus Budget Reconciliation Act (COBRA) Cases

Updating the following subsections:

  • Title- Replace Philadelphia Disability Processing (PH-DPU) with Office of Disability Operations Disability Processing Branch (ODO DPB)

  • Introduction- Replace PH-DPU with ODO DPB

  • Subsection B Title- Replace PH-DPU with ODO DPB

  • Subsection B-

    • First Paragraph Replace PH-DPU with ODO DPB

    • Bullet 6- Replace PH-DPU with ODO DPB

    • Bullet 7- Replace PH-DPU with ODO DPB

    • Bullet 8- Replace PH-DPU with ODO DPB

Bullet 9- Replace PH-DPU with ODO DPB

DI 11080.010 Disability Processing Branch (ODO DPB) and Disability Determination Services (DDS) Processing Instructions for Consolidated Omnibus Budget Reconciliation Act (COBRA) Cases

The effective date is February 28, 2019.

ODO DPB has jurisdiction over COBRA-only claims when the individual, spouse or child does not meet the non-disability requirements for title II or title XVI disability programs, or the individual only wants COBRA coverage extended for an additional 11 months and does not want to file for disability benefits. The DDS retains jurisdiction of all COBRA claims when a disability claim is associated with the case. For COBRA provisions and background, refer to Consolidated Omnibus Budget Reconciliation Act (COBRA) DI 11080.001.

NOTE: 

Due to the time sensitive nature of these claims, process COBRA cases in an expedited manner applying existing policy to make a disability determination.

A. Documents needed for COBRA case processing

COBRA-only cases are Electronic Disability Collect System (EDCS) exclusions. The field office (FO) will assemble COBRA cases using a yellow modular folder. The individual is not filing for disability benefits therefore the FO does not obtain a title II or title XVI disability application.

The paper folder contains the following information:

  • Report of Contact SSA-5002 with the following information:

    • Policyholder name

    • Social Security Information (SSN)

    • Qualifying event

    • Date of qualifying event (explanation and date of why the claimant stop working)

    • Insurance carrier

  • Due to time sensitivity, the claimant may request that we fax the determination to the health insurance company. In order for us to fax a copy of the notice, the claimant must provide a signed SSA-3288 with the following information:

    • Statement giving permission to fax to third party

    • Name of health insurance company

    • Fax number of the health insurance company

  • The appropriate disability report forms

    1. 1. 

      SSA-3368 Disability Report Adult; or

    2. 2. 

      SSA-3820 Disability Report Child; or

    3. 3. 

      SSA-3441 Disability Report –Appeal; and

    4. 4. 

      SSA-827 Authorization to Disclose Information to the SSA

See Processing Consolidated Omnibus Budget Reconciliation Act (COBRA) Disability Cases for full FO processing DI 11080.005.

B. ODO DPB case processing

The FO mails COBRA-only cases to the ODO DPB via FedEx for a medical determination. Follow normal policies and procedures when processing COBRA-only disability determination. There are no changes in the requirements to be determined disabled for COBRA-only cases.

  • When there is insufficient medical evidence in the file, there may be a need to order consultative exams (CE). For more information see, Development of Consultative Examinations (CE) DI 22510.000.

  • All referrals for CEs are requested using form SSA-448. Write COBRA in red ink at the top of the form.

  • Develop for medical evidence of record (MER) in accordance with existing policy. For more information, which explains MER development refer to DI 22505.000.

  • Consider steps to expedite development outlined in DI 22505.006B.2.

  • Review the case for a special “COBRA CASE” handling flag. The flag will include the date that the employee or dependent must notify the health plan administrator to prevent termination of COBRA coverage. If the FO omitted this information, development is needed. Contact the claimant for the necessary dates.

  • After case review, ODO DPB adjudicators are responsible for completing the document processing systems exhibit notice.

Exhibit of Notice of COBRA Allowance

Exhibit of Notice of COBRA Disallowance

  • ODO DPB adjudicators are responsible for forwarding the final determination notice to the claimant. Adjudicators must ensure proper retention of the determination notice. Fax a copy of the notice into the Non-disability Repository for Evidentiary Documents (NDRED) system annotating “COBRA Determination” on the fax coversheet.

  • A ODO DPB Supervisor or Team Leader reviews and signs for all COBRA-only cases.

  • Once all COBRA-only determinations are completed the ODO DPB must hold the case folder for 65 days before sending the completed case folder with copies of the determination and a completed “Notice of COBRA Determination” back to FO using form SSA-408 Routing Slip.

NOTE: 

Follow the same process as above for reconsideration appeals.

C. DDS COBRA case processing

The Social Security Administration (SSA) processes COBRA and disability claims following the same rules applicable to all disability claims. If the claimant requests we send the determination notice directly to the health insurance company due to time constraints, and there is a signed SSA-3288 in file with authorization, fax a copy of the determination to the health insurance company.

Simultaneous COBRA and disability claims are forwarded to their servicing DDS office using EDCS. The servicing DDS will review all documentation through eView. See DI11080.010A for documents needed and DI 11080.010D for special onset circumstances.

D. DDS responsibilities when establishing disability onset (EOD) for simultaneously filed disability and COBRA determination request

  1. 1. 

    COBRA Extension Request submitted simultaneously with a title II disability claim

    The title II EOD cannot be before the claimant’s date first insured for SSA disability benefits, see DI 25501.300A.6.

    For all cases involving a COBRA extension request based on established disability within the first 60 days of COBRA coverage, SSA must review the case for two possible onsets. One is based on the rules for establishing EOD for titled II claims, and one is for entitlement to a COBRA extension.

    If the EOD for title II is not within the first 60 days of COBRA coverage do the following:

    1. a. 

      Determine the actual EOD. If the DDS is unable to establish the exact onset date, they should determine if the disability existed within the first 60 days of COBRA coverage.

    2. b. 

      If the DDS is unable to find onset within the first 60 days of COBRA coverage, send an alert via Assistance Request (AR) through EDCS to the FO informing them that the DDS is unable to establish onset within the first 60 days of COBRA coverage. Continue processing the claim through normal development procedures.

  2. 2. 

    COBRA Extension Request submitted simultaneously with a title XVI disability claim properly establishing title XVI EOD is critical for the proper processing of the title XVI and COBRA simultaneously filed claims. When establishing the earliest possible EOD for the title XVI claim, SSA uses either the application filing date or the protective filing date, see DI 25501.370.

    If the application filing date or the protective filing date is not within the first 60 days of COBRA coverage do the following:

    1. a. 

      Determine the actual EOD. If the DDS is unable to establish the exact onset date, they should determine if the disability existed within the first 60 days of COBRA coverage.

    2. b. 

      If the DDS is unable to find onset within the first 60 days of COBRA coverage, send an alert via AR through EDCS to the FO informing them that the DDS is unable to establish onset within the first 60 days of COBRA coverage. Continue processing the claim through normal development procedures.

E. References

  • DI 11080.001 Consolidated Omnibus Budget Reconciliation Act (COBRA)

  • DI 11080.005 Processing Consolidated Omnibus Budget Reconciliation Act (COBRA) Disability Cases


DI 11080 TN 3 - Consolidated Omnibus Budget Reconciliation Act (COBRA) - 10/18/2019