Identification Number:
DI 25501 TN 15
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Onset
Type:POMS Transmittals
Program:Disability
Link To Reference:
 
PROGRAM OPERATIONS MANUAL SYSTEM
Part 04 - Disability Insurance
Chapter 255 - Onset/Duration/Closed Period
Subchapter 01 – Onset
Transmittal No. 15, 12/2017

Audience

PSC: DE, DEC, RECONR
OCO-ODO: CTE, CTE TE, DE, DEC, DS, RECONE
OCO-OEIO: CR, ERE, FCR, FDE, RECONE
ODD-DDS: ADJ, DHU
OQR: DE, PE, TL, PA
RO: Center for Disability Programs
OHO/OAO: Hos

Originating Component

ODP

Effective Date

Upon Receipt

Background

The field office (FO) is responsible for determining the potential onset date (POD). The Disability Determination Services (DDS) uses the POD to initiate medical development and to establish an onset date for disability benefits. A review conducted by the Office of Budget, Finance, Quality, and Management indicated that POD development was problematic. We changed the policy and now require that the FO enter the POD in all Title II claims.

Summary of Changes

DI 25501.220 Potential Onset Date (POD)

We made the following changes:

    · In subsection A.1. What is the POD? We added clarifying language to define the POD.
    · In subsection A.2. The POD is an alert. We added a NOTE.
    · In subsection A.3. The POD is claim-specific. In the second bulleted item, we changed the wording from “considers the POD for each disability claim type where all non-medical requirements are met.” to “must enter the POD for all Title II disability claims.” We added a third bulleted item to explain when the FO must provide the POD for Title XVI claims.
    · In subsection A.3. in the IMPORTANT statement, we changed the word “considers” to “provides.”
    · In subsection A.4., we rearranged the sentences in the first paragraph and put them into a bulleted format. We removed a redundant statement. In the IMPORTANT statement, we changed the paragraph format to a bulleted format for easier readability. In the last paragraph, we specify who will forward claims to the payment center.
    · In subsection B.1., we clarified the FO roles and rearranged them into a bulleted format for easier readability. We changed the word “considers” to “must” throughout, we clarified the reminder, and added one POMS reference.
    · In subsection B.2. DDS roles, we moved the IMPORTANT statement to the last page under DDS instructions.
    · In subsection C. Component instructions regarding the POD, we added a new IMPORTANT statement.
    · In subsection C.1.a. FO instructions for Title XVI claims, we combined and bulleted the IMPORTANT statement, exception, and note under IMPORTANT REMINDERS.
    · In subsection C.1.b. POD for Title II claims, we deleted the second paragraph since the instructions for statutory blindness claims are already in subsection A.4. We also added a fifth bullet about receiving military pay without performing SGA. In the chart, we added clarification regarding CDB claims.
    · In subsection C.2. DDS instructions, we rearranged the instructions into a bulleted format, changed the note and caution statements into bullets, and split out the instructions for Title II claims and Title XVI claims separately. We added a note to provide additional DDS instructions regarding when they do not have to contact the FO to update the POD. We moved the DDS instructions for contacting the FO to this section that we deleted in subsection B.2. DDS roles.





DI 25501.220 Potential Onset Date (POD)

A. Introduction to the POD

1. What is the POD?

The POD is the earliest possible date that the adjudicator can use to establish the established onset date (EOD) based on non-medical factors. This date may be the same as, earlier, or later than the alleged onset date (AOD). For more information on AOD, see DI 25501.210.

The field office (FO) determines the POD by evaluating non-medical factors, such as work activity or periods of eligibility for benefits. The disability determination services (DDS) must consider both the POD and the AOD when determining the EOD.

2. The POD is an alert

The POD guides disability case development. The FO claims specialist enters the POD to alert the DDS about:

  • work issues that suggest possible disability entitlement earlier or later than the AOD (e.g., work after onset, a reduction of work hours that may reduce work activity below the level of substantial gainful activity (SGA), and possible unsuccessful work attempts (UWA)), see DI 25501.220C.1.b. in this subsection, or

  • other non-medical factors (e.g., date first or last insured and prescribed period) limiting the DDS consideration of disability entitlement to a period earlier or later than the AOD.

NOTE: The POD may be in a previously adjudicated period, including a period decided by an administrative law judge (ALJ). The DDS will determine if reopening applies or if they can set the EOD in the prior period. See DI 25501.250 and DI 25501.220C.2.c in this subsection.

3. The POD is claim-specific

Prior to transferring an initial or reconsideration level claim to the DDS for a disability determination, the FO claims specialist:

  • completes the EDCS 3367 or SSA-3367 (see DI 11005.045),

  • must provide the POD for all Title II disability/concurrent disability claims, and

  • must provide the POD for Title XVI claims if the POD is different from the filing date or the protective filing date.

IMPORTANT: If there is more than one claim type, the FO must provide the POD for each disability claim type separately.

4. The POD does not apply to claims involving visual impairments or blindness

The POD:

  • pertains to potential non-blind disability entitlement factors only.

  • does not guide development for statutory blindness. Therefore, the DDS may only use the POD to determine an onset based on disability rather than statutory blindness.

IMPORTANT: The POD does not apply in new Title II claims filed

following a prior period of statutory blind entitlement ceased due to:

  • substantial gainful activity (SGA), or

  • a disability freeze based on statutory blindness only (no cash benefits).

In these situations, the FO forwards claims to the payment center (PC) after making SGA determinations and the DDS forwards freeze claims to the PC for disability insurance benefits (DIB) attainment processing per DI 13010.135G.

For detailed information on statutory blindness development, evaluation, and processing, see DI 26000.000 Statutory Blindness Cases – Development, Evaluation and Processing Issues – Table of Contents.

B. Component roles regarding the POD

1. FO roles

The FO:

  • documents work activity on the SSA-821-BK or SSA-820-BK, including potential continued work or work after the AOD,

  • makes SGA determinations and records possible Trial Work Period (TWP) months on the SSA-823 (unless the work was clearly not SGA). For detailed information to determine if work is or is not SGA, see DI 10505.003,

  • must enter the POD for each Title II disability claim type on the SSA-3367 (see the chart in DI 25501.220C.1.b.in this subsection), and

  • must enter the POD for Title XVI claims on the SSA-3367 if the POD is different from the protective filing date or the filing date.

REMINDER: For concurrent claims or for multiple Title II claims, the FO must provide the POD separately for each disability claim type.

NOTE: Never assign a POD on a technical denial, for example, due to an SGA denial, because there is no possibility of disability entitlement on the claim.

For related instructions, see also:

  • DI 10501.015 for the SGA Earnings Table

  • DI 10501.025 for making an SGA determination if the work is clearly not SGA

  • DI 10505.035 for completing the SSA-821-BK and SSA-823

  • DI 10510.025 for completing the SSA-820-BK and SSA-823

  • DI 11010.075 for Disability Insurance Benefits (DIB) and MQGE claims

  • DI 11015.030 for Disabled Widow(er)’s Benefit (DWB) claims

  • DI 11020.050 for Childhood Disability Benefit (CDB) claims

  • DI 11055.095 for Supplemental Security Income (SSI) claims

2. DDS roles

The DDS:

  • focuses all disability case development on the POD,

  • uses the POD when determining the earliest possible EOD, and

  • makes a final UWA determination, if applicable.

C. Component instructions regarding the POD

IMPORTANT: Do not deny a disability insurance benefit (DIB) claim based on insured status for a claimant alleging a visual impairment before determining the statutory blind insured status. Do not use the non-medical complete (NMC) function for Title II claims when the claimant alleges blindness or a visual impairment. For detailed information, see DI 11005.070 Field Office Title II and Title XVI Disability Claims for Blindness and Visual Impairment Allegations.

1. FO instructions

Provide a POD for each disability claim type as follows:

a. POD for Title XVI claims

The POD is generally the protective filing date or the filing date if there is no protective filing.

IMPORTANT REMINDERS:

  • If the POD is the same as the protective filing date or the filing date, the FO does not need to enter the POD on the EDCS 3367 or the SSA-3367; refer to DI 11005.045A.1.c.

  • If SGA ceased after the protective filing (or filing) date, the POD is the last date the claimant performed SGA.

  • SGA limits apply in Title XVI initial claims with the exception of those medically determined to meet statutory blindness.

b. POD for Title II claims

For most Title II claim types, the POD is the AOD unless non-medical factors result in a different POD. See the chart below.

To determine the POD:

  1. Consider whether a technical factor(s) such as date first insured (DFI), date last insured (DLI), controlling date, the attainment of age 22, and SGA are material.

  2. If no technical factor limits the POD to a date later than the AOD, consider whether the POD could be earlier than the AOD.

Evaluate these situations on a case-by-case basis. An earlier POD might be appropriate when allegations indicate impairment(s) existed prior to the AOD, and the claimant was working prior to the AOD, but you determine the work was not SGA. For example, prior to the AOD the claimant may have:

had subsidized employment,

had income below SGA,

had a UWA, as recommended to the DDS by the FO, or

been in pay status, but out on sick leave or received other type(s) of non-countable income after the date last worked (for information on military pay and SGA, or

received military pay without performing SGA, see DI 11005.006B.

EXAMPLE of an earlier POD: A claimant had a heart attack on 04/26/2010. From 04/27/2010 through 06/26/2010, he did not work but received sick pay. On his application, he alleged disability because of the heart attack and stated his disability began on 06/27/2010, when his sick pay ended. His POD would be 04/26/2010, the date of his heart attack, even though his AOD is 06/27/2010.

EXAMPLE of a later POD: A claimant alleges disability since 11/02/2009. On his application, he indicated he performed SGA until 10/30/2009 and from 12/17/2009 until 03/15/2010, after the AOD. The POD may be 03/15/10, the day the claimant last performed SGA, although it may be 10/30/2009 if the FO believes a UWA is likely.

3. Document the POD determination on the EDCS 3367 or the SSA-3367.

NOTE: Document all work issues on forms SSA-820-BK or SSA-821-BK and document SGA determinations and TWP issues on the SSA-823 (see DI 10510.025 and DI 10505.035).

Consider the factors listed on this chart when determining the POD:

Claim Type

The POD is generally:

Disability Insurance Benefits (DIB)

the latest of:

  • AOD,

  • date the claimant last performed SGA, or

  • DFI.

Disabled Widow(er) Benefits

(DWB)

the latest of:

  • AOD,

  • date the claimant last performed SGA, or

  • controlling date.

REMINDER: If the claimant performed SGA through the end of the prescribed period, there is no POD and no DWB entitlement. For related policy, see DI 10110.001D and DI 11005.050A.

Childhood Disability Beneficiary-Retired or Deceased

(CDB-R) (not re-entitlement)

the earliest date that provides the claimant with a fully favorable EOD, and also:

  • Precedes the month of attainment of age 22,

  • Is no earlier than the date the claimant last performed SGA, and

  • Affords maximum retroactivity of 6 months based on the filing date and the NH’s entitlement month or date of death.

For more information refer to the chart in DI 25501.330A.9.

Childhood Disability Beneficiary-Disabled

(CDB-D) (not re-entitlement)

the earliest date that provides the claimant with a fully favorable EOD, and also:

  • Precedes the month of attainment of age 22,

  • Is no earlier than the date the claimant last performed SGA, and

  • Affords maximum retroactivity of 12 months based on the filing date and the NH’s entitlement month.

For more information refer to the chart in DI 25501.330A.8.

REMINDER: If the applicant has never been entitled to CDB benefits and the FO cannot establish the POD prior to age 22 because of SGA performed after age 22, the FO must deny the claim for SGA. See DI 10115.022B.

CDB Re-entitlement

the latest of:

  • AOD,

  • date the claimant last performed SGA, or

  • date the youngest child-in-care attained age 16.

REMINDER: CDB benefits may be reinstated after the usual 84-month period (7 years) if the beneficiary’s previous disability entitlement terminated because of the performance of the CDB claimant’s own SGA. See DI 23505.010A.

Disabled Minor Child

(DMC)

the latest of:

  • AOD,

  • date the child last performed SGA,

  • date the youngest child-in-care attained age 16, or

  • controlling date (the first date the parent can be entitled to benefits).

For related information about DMC claims, refer to DI 11025.010 and DI 23505.001.

Medicare for Qualified Government Employment (MQGE)

the latest of:

  • AOD,

  • DFI,

  • date the claimant no longer performed SGA, or

  • 17 months prior to the protective filing date (or filing date if there is no protective filing date).

For related information about MQGE claims, refer to DI 11035.000.

For instructions on documenting the POD, see:

DI 11005.045 Completing the SSA-3367 (Disability Report-Field Office)

DI 81010.025 Completing Electronic Disability Collect System (EDCS) Forms for Initial Claims.

NOTE: If the FO must update the POD while the claim is under DDS jurisdiction, use the update after transfer (UAT) process.

2. DDS instructions

The DDS uses the POD to guide initial and supplemental development and when establishing the EOD. Depending o