When an appeal determination/decision of a medical cessation (or adverse medical reopening/revision)
is made at the reconsideration or ALJ hearing level (or the ALJ dismisses the request
for an ALJ hearing), the affected individual will receive a notice from Disability
Determination Services (DDS) or the Hearing Office (HO) about the appeal determination,
decision or dismissal.
If SBC payments were being received during his/her appeal process:
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When the appeal determination/decision by DDS or HO is favorable, the FO will terminate SBC payments and reinstate regular payments.
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When the determination/decision is unfavorable (or there is a dismissal of the request for an ALJ hearing), then the notice will
include appeals language and SBC payments must be terminated.
The FO must terminate SBC in the appropriate month and in a timely manner. Any months
of SBC will be an overpayment, subject to all the usual waiver rules.
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See Waiver Provisions for Title II and Title XVI Overpayments, GN 02250.000.
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The DDS will input an unfavorable determination on the appeal.
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The system will automatically terminate SBC based on the data from the DDS input for
Title XVI cases.
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A Post-entitlement Online System (POS) input is required for termination of Title
II benefits. See MSOM T2PE 002.003 for transmitting data to terminate Title II benefits.
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The HO will input an unfavorable decision on the appeal (or dismissal of the request
for an ALJ hearing).
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The system will automatically terminate SBC based on the information from the HO input
for Title XVI cases.
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In Title II cases, the HO input may not automatically terminate SBC payments. A case
is automatically terminated if it meets all of the following criteria:
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Case input by HO within 30 days of the ALJ decision
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Hearing type indicates SBC is involved, and
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Case coded as a medical cessation
Title II cases not meeting this criteria require further action to terminate SBC payments.
The FO will terminate benefits for Title II cases by a POS input. See DI 12027.010C.
3. Appeals Council (AC) Remand
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See DI 12027.060 about processing SBC in AC remands of Title II cases.
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See DI 12027.065 about processing SBC in AC remands of Title XVI or concurrent Title II/Title XVI
cases.