SSA - POMS: DI 23050.001 - Disability Determination Services (DDS) Instructions for Re-entitlement to Disability Benefits and Medicare

A. Policy for applying prior entitlement months to the Medicare waiting period for a new disability benefit

The Social Security Administration (SSA) may count months from previous periods of disability benefit entitlement toward the 24-month Medicare waiting period for a new current disability benefit if one of the following applies:

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a prior period of Disability Insurance Benefits (DIB) entitlement ended no more than 5 years (60 months) before the month of current established onset date;
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a prior period of Disabled Widow(er)’s Benefits (DWB) or Childhood Disability Benefits (CDB) entitlement ended no more than 7 years (84 months) before the month of current established onset date;
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the current disabling impairment is the same as, or directly related to, the impairment that served as the basis for disability during a previous period of disability entitlement (applies to individuals whose prior period of entitlement ended on or after 03/01/88); or
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SSA re-entitles an individual to disability benefits with the same disability onset date as a previous disability entitlement that ended for non-disability reasons prior to 03/01/88. (If the individual's previous period of entitlement ended on or after 03/01/88, SSA may count months of that prior entitlement under the preceding rule.)

A person does NOT have to be reentitled to the same type of disability benefit for these rules to apply.

The field office (FO) will process the Medicare waiting period information if the current onset is less than 5 years (7 years for DWB or CDB) after the prior termination. (For information about FO applying prior entitlement months to the Medicare waiting period, see DI 11010.261.)

B. DDS role in applying prior entitlement months to the current Medicare waiting period

If the current onset is more than 5 years (7 years for DWB or CDB) after the prior termination, then the FO will request DDS assistance with determining the Medicare waiting period information.

If the current onset is more than 5 years (7 years for DWB or CDB) after the prior termination, DDS will consider whether:

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the current impairment is the same as or directly related to the prior impairment; and
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the prior period of disability benefits entitlement ended 03/01/88, or later.

C. DDS Medicare waiting period development procedures

1. Case development for the Medicare waiting period

When you receive the case, review the SSA-3367 (Disability Report - Field Office) and other case documentation for:

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the remark, “Medicare Waiting Period Determination Needed.”
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the FO-provided prior entitlement Diagnosis Code(s)

When you complete case development, make the current disability determination.

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If the current determination is a denial, do not provide special processing, notice paragraphs, or comments on the Medicare waiting period. Process the denial according to existing procedures.
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If the current disability claim is an allowance, make a separate Medicare waiting period decision according to the instructions in this subsection.

NOTE: While DDS will make the onset determination for the current allowance, DDS does not establish any time frame for the Medicare Waiting Period.

2. Making the Medicare waiting period determination

If the current disability claim is an allowance, you will then determine if the current impairment is the same as or directly related to the prior impairment.

Compare the prior diagnosis with the current diagnosis to determine if the current impairment is the same as or directly related to the prior impairment.

a. Comparison to file

Compare the primary and secondary diagnoses and impairment codes shown on the most recent prior SSA-831 (Disability Determination and Transmittal) or SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal - Title II) to those on the current SSA-831.

b. Comparison to diagnosis code(s)

Compare the FO-provided Diagnosis Code to the current primary or secondary diagnosis codes in blocks 16A and 16B on the current SSA-831.

If the first three digits of the Diagnosis Code are the same as the first three digits of the primary or secondary diagnosis codes shown in blocks 16A or 16B on the current SSA-831, determine the current impairment to be the same as, or directly related to the impairment upon which we based the previous entitlement.

NOTE: If the current impairment is HIV and you see the impairment codes 042, 043, 044, or 279, you can determine that the impairment is the same as or directly related to the impairment upon which we based the previous entitlement (over the years we used various impairment codes for HIV cases).

c. No basis for comparison

Systems queries may show a prior title II disability entitlement, but you have no:

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prior SSA-831 or SSA-833 to compare impairment diagnoses;
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diagnosis code information; and
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no way to link the current and prior causes of disability.

In this case, presume that the current impairment is the same as or directly related to the impairment upon which we based the previous entitlement, provided there is no evidence to the contrary.

3. Processing the favorable determination

a. Fully favorable determination

A fully favorable Medicare waiting period determination exists when you determine that the current impairment is the same as or directly related to the impairment upon which we based the previous entitlement.

If you will make a fully favorable Medicare waiting period determination and the current impairment is the same as or directly related to the prior impairment, enter the following in Item 34 (Remarks) on the SSA-831: “Count prior months of benefit entitlement toward Medicare waiting period.”

b. Partially favorable determination

A partially favorable Medicare waiting period determination exists when you determine that the current impairment is not the same as or directly related to the prior impairment.

If you make a partially favorable Medicare waiting period determination, enter the following in Item 34 (Remarks) on the SSA-831: “Do not count prior months of benefit entitlement toward Medicare waiting period.”

The DDS prepares a personalized paragraph explaining that the current impairment is not the same as or directly related to the prior impairment.

Follow these steps to prepare the personalized paragraph:

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Prepare the personalized paragraph on an SSA-4268-U4/C4 (Explanation of Determination).
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Use the paragraph and fill-ins in NL 00720.180 HIB190.
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Add a statement to describe the prior and current impairments.

NOTE: The FO prepares the notice that explains the Medicare waiting period determination. The FO-prepared notice will include the DDS personalized paragraph, and it will include appeal rights information.

Social Security

Program Operations Manual System (POMS)

DI 23050.001 Disability Determination Services (DDS) Instructions for Re-entitlement to Disability Benefits and Medicare