Previously entitled beneficiaries, whose entitlement ended due to work, are eligible for EXR if they meet all of the following requirements:

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  are “not able” or “becomes unable” to work at the SGA level due to their medical condition,

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  are “not able” or “becomes unable” to perform SGA in the month of the EXR request,

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  stopped performing SGA and request EXR within 60 months of their prior termination,

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  have a current medical impairment(s) that is the “same as or related” to the original impairment(s), and

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  are under a disability based on application of the medical improvement review standard (MIRS).

Claimants are “not able” to perform SGA if, in the month of their EXR request or the following month, they do not work or their work is not SGA.

Claimants “become unable” to perform SGA if, in the month of their EXR request, their work is SGA, but they stop performing SGA by the day they file their request. To meet the requirement of having become unable to perform SGA, they must also not perform SGA in the month following the EXR request.

NOTE: Claimants whose prior entitlement is a closed period of disability are not eligible for EXR.

A beneficiary or recipient reinstated under EXR receives a 24-month initial reinstatement period (IRP). The IRP is completed when the individual has received a total of 24 months payable benefits. After completing the IRP, a Title II beneficiary gets a new trial work period (TWP) and an extended period of eligibility (EPE). If benefits terminate again after completing the EPE, we may reinstate a Title II claimant through a new request for EXR, if the claimant meets the EXR eligibility criteria. After completing the IRP, we can reinstate Title XVI claimants whose benefits stop due to work through a new request for EXR, if the claimant meets EXR eligibility criteria. For more information on the IRP, see DI 13050.066 and DI 13050.067.

Claimants previously entitled to disability insurance benefits (DIB), disabled widow(er) benefits (DWB), or an unmarried childhood disability benefit (CDB) whose monthly benefits terminated due to their own SGA must meet the requirements listed in DI 13050.001B.1 in this section to be eligible for EXR.

NOTE: The EXR provision is applicable to a Medicare Qualified Government Employee (MQGE) beneficiary, which allows reinstatement to Medicare, even though we do not pay monthly benefits.

If we deny a request for EXR for failure to meet the non-medical requirements for EXR (not filed within 60 months, etc.), we may apply the principles of res judicata to a subsequent request. Res judicata does not apply if any aspect of the case has changed, including laws or regulations. For situations in which res judicata is applicable, see GN 03101.160B.

If a claimant requesting EXR is currently entitled to another disability benefit, do not apply collateral estoppel procedures to approve the EXR request. The Disability Determination Services (DDS) must make the medical determination that the impairment is the same as or related to the impairment that was the basis for the previous entitlement and the claimant must be disabled. To determine disability for EXR requests, we use the medical improvement review standard (MIRS).

If the claimant became entitled to reduced RIB simultaneously with or after the EXR month of entitlement (MOE), see RS 00615.110B.2. If the claimant became entitled to reduced RIB before the EXR MOE, see RS 00615.110B.3.

NOTE: For retirement benefit computation purposes, consider the period of disability and the EXR period to be one period of DIB.

When we approve a number holder’s request for EXR, an auxiliary on the original record can file for reinstatement on the record. The auxiliary must file a new application for benefits and must continue to meet initial entitlement requirements, per DI 13050.060A.2.

A previously entitled recipient whose monthly benefits terminated due to excess earned income (or a combination of earned and unearned income) must meet the requirements listed under DI 13050.001B.1 in this section and meet all non-medical Title XVI requirements to be eligible for EXR.

If we deny a request for EXR for failure to meet the non-medical requirements for EXR (not filed within 60 months, etc.), we may apply the principles of res judicata to a subsequent request. Res judicata does not apply if any aspect of the case has changed, including laws or regulations. For situations in which res judicata is applicable, see GN 03101.160B.

An eligible spouse can also request reinstatement and may be eligible for up to 6 months of provisional benefits and Medicaid coverage during the provisional benefit period.

A claimant must complete the 24-month IRP to qualify for a subsequent period of EXR entitlement. If a claimant has not completed the IRP, they do not qualify for a subsequent period of EXR.

EXAMPLE: We reinstated Smith’s Title XVI benefits through EXR as of 3/18. Smith returns to work as of 6/19 and has earnings over the threshold amount, making them ineligible for cash benefits. Smith continues to work, and their Title XVI benefits terminate as of 6/20 after 12 months of payment ineligibility. Smith contacts SSA in 7/21 to state that they are no longer able to perform SGA and wants to apply for EXR. Since Smith only completed 15 months of their IRP (3/18 through 5/19), they are not eligible for reinstatement under EXR.

Evaluate a blind claimant's work activity under standards applicable to beneficiaries with statutory blindness in Title II (blind SGA standards) and Title XVI (blind work expenses) see DI 10515.000 and SI 00820.535.

To qualify for EXR, the statutorily blind claimant must undergo the same medical review process as a non-blind disabled claimant. The claimant must undergo the “same as or related” determination, and a MIRS review. The DDS will make an EXR decision and then a comparability decision, if necessary, for a claimant over age 55. If approved, the FO will process the award in the same manner as other EXR cases. Do not use the DIB attainment process normally used to re-entitle a claimant to cash benefits in Title II EXR processing. For more information on DIB attainment, see DI 13010.135 and DI 41005.010.

EXR is applicable for blind claimants only if they completed the TWP and their benefits terminated based on SGA. If the claimant is currently in suspense status, they do not meet the requirements for EXR, see DI 10515.015B.

The FO is responsible for taking the following actions:

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  Discuss the criteria for reinstatement with the claimant and provide a comparison of the possible effects of requesting EXR versus filing a new initial claim. For complete instructions on EXR versus a new claim, see DI 13050.020. For complete EXR interview instructions, see DI 13050.045 and DI 13050.050.

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  Assist the claimant with the request for reinstatement and determine whether the claimant meets the applicable non-medical criteria.

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  Obtain the necessary forms as instructed in DI 13050.045 and DI 13050.050.

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  Obtain the prior medical folder if the prior decision was not electronic.

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  Initiate provisional benefits via the Post Entitlement Online System (POS) (if applicable) for Title II, or by establishing a start-date record for Title XVI. For complete provisional benefit instructions, see DI 13050.025 and DI 13050.030.

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  For Title II, the FO identifies all SGA and non-SGA months in the 12-month period prior to the month of filing or from the benefit termination month (BTM), whichever is later, in item 2C of the Continuing Disability Review/Post Entitlement (CDR/PE) section on the SSA-823 and documents first possible month of entitlement regardless in MM/YY format regardless of SGA.

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  If the claimant meets all the non-medical requirements for EXR, the FO transfers the case to the DDS for a medical determination.

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  Establish EXR on the Disability Control File (DCF).

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  If the claimant does not meet the non-medical requirements for EXR, and the claimant insists on filing for EXR, the FO issues a technical denial. For technical denial instructions, see DI 13050.065.

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  If the DDS allows the EXR,

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    For Title II, the FO processes an Electronic Form 101 (EF101) per DI 13050.060B, and forwards it to the program center (PC) for processing, see EXR EF101 Guide.

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    For Title XVI, the FO will terminate the record, stops provisional benefits, and then start-date a new EXR record.

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  If DDS denies the EXR, terminate provisional benefits if currently being paid.

  For complete EXR award instructions, see DI 13050.060 and DI 13050.061.

The DDS reviews the medical evidence and determines if the claimant's current impairment is the “same as or related” to the impairment that led to the previous entitlement to benefits, using the comparison point decision (CPD). If a “same as or related impairment” exists, the DDS will determine whether the claimant is disabled based on the MIRS. The DDS determines the EXR month of entitlement in allowance determinations. The DDS prepares an SSA-832 Title XVI Cessation or Continuance of Disability Determination and Transmittal, or SSA-833 Title II Cessation or Continuance of Disability to document the determination. If the DDS allows the EXR, the DDS will return the case to the FO. If the DDS denies the EXR, the DDS will prepare and send the denial notice containing a Personalized Explanation to the claimant, before returning the case to the FO. For complete instructions on DDS EXR claims processing, see DI 28057.000.

NOTE: The determination that an impairment is "the same as or related to" is a medical determination that can be made only by the DDS.

The PCs process all EXR awards for Title II benefits through the District Office Final Authorization (DOFA) procedures. The PC will:

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  Terminate provisional benefits, if necessary, and adjust the benefits payable for provisional benefits paid, and

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  Adjudicate Medicare entitlement as appropriate, and

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  Prepare and send the appropriate award and overpayment notices. For PC EXR procedures, see SM 00856.000 and DI 13050.095.

NOTE: The DCF controls EXR requests from the time of the request through adjudication. It is important to initiate the EXR event on the DCF and show the transfer of the case between the FO, DDS, and PC to control the cases accurately, and to provide accurate management information. Further, controlling the EXR case through the DCF helps ensure the accuracy of future actions during the IRP, TWP, and EPE (if applicable).