PROGRAM OPERATIONS MANUAL SYSTEMPart DI – Disability InsuranceChapter 255 – Onset/Duration/Closed PeriodSubchapter 01 – OnsetTransmittal No. 32, 10/21/2021
This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.
Summary of Changes
DI 25501.365 Established Onset for Medicare Qualified Government Employment (MQGE) Claims
In DI 25501.365A.5, changed the first word in the first sentence from "Benefit" to "Deemed DIB" so it now reads "Deemed DIB entitlement is retroactive for up to 12 months from the filing date."
Federal, state, and local government employees, who are only subject to the Medicare portion of the Federal Insurance Contribution Act (FICA) tax, earn quarters of coverage (QCs) that insure the employee for Medicare entitlement purposes only. We credit QCs for MQGE purposes for the same amount of wages and in the same manner as Social Security QCs.
A claimant who worked for both a government employer and non-government employer may be insured for both MQGE and Disability Insurance Benefits (DIB). However, date first insured (DFI), date last insured (DLI), and potential onset date (POD) may differ for each type of claim.
For the disability requirement of the law, we evaluate MQGE using the same criteria we use to evaluate title II DIB claims.
For MQGE claims, we cannot establish the EOD before substantial gainful activity (SGA) ceases.
The DFI is the first day of the quarter a claimant first meets insured status. A claimant must meet insured status requirements to establish entitlement to MQGE benefits. The EOD cannot be before the DFI. However, the adjudicator may consider the period before the DFI to determine whether the claimant’s condition meets the 12-month duration requirement.
An MQGE claimant must serve the equivalent of the DIB five-month waiting period in addition to the 24-month Medicare eligibility period. In the case of a Childhood Disability Benefit (CDB MQGE claimant, there is only a 24-month Medicare eligibility period.
EXCEPTION: We waive the 24-month qualifying period for Medicare coverage for disabled claimants we medically determine to have Amyotrophic Lateral Sclerosis (ALS), commonly known as Lou Gehrig’s disease (see DI 11036.001B). For more information about ALS and Medicare entitlement, see DI 23580.001.
Deemed DIB entitlement is retroactive for up to 12 months from the filing date. An EOD established as of 17 months before the filing date provides maximum retroactivity, because it includes the five-month waiting period.
The EOD is the date that a claimant meets the definition of disability and all the relevant entitlement or eligibility factors. Establish the EOD on the earliest possible date based on the claimant’s alleged onset date (AOD), POD, DFI, date last insured (DLI), and the medical and other evidence in the file. The same policies and procedures for EOD in DIB claims apply to MQGE claims, see DI 25501.300.
The field office (FO) provides the Disability Determination Service (DDS) and the Office of Disability Adjudication and Review (ODAR) with the claimant’s AOD, POD, DFI, and DLI and alerts the DDS the case is an MQGE claim. If a claimant is potentially entitled to both MQGE and DIB benefits with different DFIs, DLIs, and PODs, the FO must indicate this on the SSA-3367-F5 (Disability Report — Field Office), to alert the DDS to develop evidence based on multiple onset dates.
The DDS develops evidence to determine when the claimant became disabled and establishes the earliest possible EOD supported by the medical evidence of record and the claimant’s entitlement and eligibility factors stated in DI 25501.365A in this section and DI 25501.300A Onset for DIB claims provided by the FO. The EOD cannot be earlier than the DFI or later than the DLI.
Generally, the DLI will propagate from the Modernized Claim System (MCS) into the Electronic Disability Collect System (EDCS). If the DLI does not propagate, enter the most recent DLI in the space provided and check the Date Last Insured box on the EDCS screens (see DI 81010.025A.1.) or in items 3 and 4 of the paper SSA-3367-F5.
Enter the POD in the EDCS-3367.
Enter the following statement in the “Explanation for Recommended Onset Date, When Applicable” box on the EDCS screens or in item 5 on the paper SSA-3367: “Possible Later DLI for Medicare purposes only due to claimant being a Medicare Qualified Government Employee.” (The DDS will contact you if they cannot establish disability before the DLI and request a MQGE DLI.)
EDCS will identify the claim as an MQGE claim once the claims representative indicates the claim is MQGE on the IND2 screen in MCS. If the claim is a concurrent DIB/MQGE, create a message in EDCS identifying the claim as a concurrent DIB/MQGE case.
Take the following actions after the FO determines the claimant’s AOD, POD, DFI, and DLI.
Secure sufficient medical and non-medical evidence that supports the earliest possible EOD based on technical factors including the DFI and the POD.
Establish the earliest possible EOD based on the claimant’s POD and the medical and other evidence in file using the policy stated in DI 25501.365A in this section. The EOD cannot be earlier than the DFI or later than the DLI.
If the FO provided only a DIB DLI and you cannot establish onset before the DIB DLI:
contact the FO to determine the MQGE DLI. Document your conversation on an SSA-5002 (Report of Contact) form, and
determine if you can establish onset on or before the MQGE DLI.
If you know the month of the EOD, but you do not know the specific day, establish the EOD on the last day of the month. However, if the AOD/POD is the first day of the month in which you establish onset, you must fully develop the claim to determine the exact EOD.
NOTE: In some instances, you may need to consider the severity of the claimant’s condition (in the absence of SGA) before the DFI, to evaluate the 12-month duration period.
If the actual onset of disabling severity predates the DFI, on the SSA-831 (Disability Determination and Transmittal), take the following actions:
Enter the EOD in item 15A.
Enter the following statement, “Item 15A is based on date first insured. Impairment(s) was of disabling severity for purposes of the duration requirement as of [enter the date],” in item 34.
NOTE: The EOD as of the DFI is fully favorable. See the second bullet in DI 25501.280A.2.
DI 11035.001 Medicare for Qualified Government Employment (MQGE) Claims Based on Disability
DI 25501.300 Onset for DIB Claims
DI 23540.001 Medicare for Qualified Government Employment (MQGE) Cases
HI 00801.440 Special Rules Applicable to MQGE Claims