Effective Dates: 03/26/2025 - Present Previous | Next

TN 10 (03-25)

DI 12027.065 Title XVI and Concurrent Title II/Title XVI Statutory Benefit Continuation When the Appeals Council Remands a Medical Cessation Case to the Hearing Level

A. Title XVI and concurrent Title II/Title XVI medical cessation cases

An individual can receive statutory benefit continuation (SBC) when the Appeals Council (AC) (or federal court by way of AC remand orders) remands a medical cessation case to administrative law judges (ALJs) at the hearing level for further action. The procedures in this section apply to Title XVI and concurrent Title II/Title XVI disability cases. For SBC procedures in Title II-only AC-remanded medical cessation cases, see DI 12027.060.

In Title XVI and concurrent Title II/Title XVI medical cessation cases remanded by the AC to the hearing level, the AC remand order includes the transmittal sheet and Supplemental Security Income (SSI) Payment Status Request alerting both the hearing office and servicing field office (FO) of the remand order and the potential SBC eligibility.

The servicing FO receives the AC's notification of the remand by email. Additionally, when the AC remands a medical cessation case to the hearing level, the case transfer generates the Electronic Disability Collect System (EDCS) action item, "Case Remanded - Potential Benefit Continuation".

IMPORTANT: 

SBC does not apply while the case is pending at the AC or federal court level. See DI 12027.001 for more information on SBC eligibility.

B. FO procedures when the AC remands a medical cessation case to the hearing level

The following procedures apply when the AC remands a Title XVI or concurrent Title II/Title XVI medical cessation case to the hearing level:

1. FO receives AC remand notification

The FO will:

  1. a. 

    Review the individual's (and any auxiliaries for Title II) eligibility to receive SBC payments.

  2. b. 

    Complete Part 2 of the SSI Payment Status Request attached to the AC's remand order. See Exhibit 1 in DI 12095.172 for a sample of the SSI Payment Status Request.

  3. c. 

    Store the SSI Payment Status Request (with the FO's response to Part 2) in eView, or in Electronic Non-Medical (ENM) for EDCS exclusions.

  4. d. 

    Notify the servicing hearing office by email.

Upon receipt of the FO's response to the SSI Payment Status Request, the hearing office will send the appropriate SBC notice to the individual and a copy to the appointed representative, if applicable. The hearing office uploads a copy of the notice to eView (or ENM for paper cases) to be viewed by the servicing FO should the individual contact the FO. The notice informs the individual about their right to reinstatement or waive SBC benefits.

If the individual elected SBC at the prior hearing level, reinstate SBC payments without a new election by following procedures in DI 12027.065C.1, in this section. If the individual did not elect SBC at the prior hearing level, follow the procedures in DI 12027.065C.3, in this section.

NOTE: 

SBC payments are not overpayments until the medical cessation decision is final. The medical cessation decision becomes final when the individual does not request further review within the appeal period (and does not have good cause for a late appeal) or has exhausted all levels of appeal. For more information see SI 02220.009 and GN 02201.009C.

2. Individual contacts FO to elect SBC before FO review

When an individual or their authorized representative contacts the FO to make an SBC election prior to the FO processing the AC remand notification, the FO will:

  • •

    Review eView to locate and confirm the remand order,

  • •

    Notify the hearing office by email and,

  • •

    Follow the applicable procedures in the tables below.

3. Follow-up after AC remand

When an individual contacts the FO for status of their remanded appeal, check eView or ENM to verify that the appeal remains pending. If it has been 120 days or more since the date of the remand order, email or call the hearing office for status.

C. FO procedures to reinstate SBC payments

To reinstate SBC, the FO will follow the applicable procedures as follows.

1. SBC elected before prior ALJ decision

When an individual elected SBC at their prior hearing request, the FO will:

  1. a. 

    Contact the individual to:

    • •

      Complete a redetermination (RZ) for Title XVI as required in SI 02305.022. For the Title II portion in concurrent cases, follow procedures in DI 12027.060C.

    • •

      Verify the individual's previous SBC election remains the same. If the individual elects not to resume SBC after the AC remand, document the individual's decision in writing and store in the electronic folder. See DI 12027.010B.8 for election statement documentation.

  2. b. 

    Process the Title XVI case in accordance with the following chart:

If the individual elects reinstatement of SBC and alleges:

Then:

No work, and according to the allegation, non-disability factors will not lower the title XVI protected payment level (PPL) amount:

  • •

    Process the RZ for non-disability Title XVI factors.

  • •

    Follow SI 04040.010G to reinstate the pending Title XVI hearing appeal.

  • •

    Notify the recipient using an SSA-L8165-U2 SSI Important Information notice in the Document Processing System (DPS) regarding their eligibility for continued payments.

  • •

    Reinstate SBC payment. Payment begins with the month terminated by the ALJ's decision.

A non-disability change (e.g., income or living arrangement change) permitting payment at less than the PPL, see SI 02301.325:

  • •

    Follow SI 04040.010G to reinstate the pending Title XVI hearing appeal.

  • •

    After completing the RZ for non-disability factors, notify the recipient using the SSA-L8155-U2 in DPS of the reduced payment amount and their right to appeal.

  • •

    Reduce the PPL retroactive to the month terminated by the now vacated ALJ decision.

Non-disability changes do not permit payment (e.g., excess resources):
  • •

    Follow SI 04040.010G to reinstate the pending Title XVI hearing appeal.

  • •

    Process the RZ for the non-disability factors.

  • •

    Notify the individual of the ineligibility for Title XVI payment based on the RZ development using an SSA-L8155-U2 notice in DPS.

  • •

    Process the adverse action to stop payments and do not release retroactive payments.

NOTE: 

Process any subsequent changes in non-disability factors as a subsequent event during a period of SBC. This includes changes in non-disability factors resulting from verification, the SSI redetermination process, or other individual contacts after reinstatement. Refer to SI 02301.001 for SSI post-eligibility changes.

2. SBC elected at the prior ALJ hearing appeal and the individual is in current pay status for a subsequent disability claim

The FO will:

  1. a. 

    Review the period from the month of the ALJ unfavorable decision to the month of entitlement from the subsequent claim to determine if there are payable SBC months due.

  2. b. 

    If an adverse Title XVI payment adjustment is needed, provide the individual advance notice prior to making the adjustment per the guidance above.

3. Individual did not elect SBC at the prior ALJ level

The FO will:

  1. a. 

    Give the individual 15 days (10 days plus 5 days for mailing) from the hearing notice date to request SBC.

  2. b. 

    Process the case in accordance with the following chart:

If the individual:

Then:

Does not contact the FO:

Take no action on SBC.

Contacts the FO after the date of the hearing office notice and requests SBC:

If contact is received within 15 days after the date of the hearing notice, complete the following steps:

  • •

    Complete an RZ for Title XVI as required in SI 02305.001. See the table in DI 12027.065C.1, in this section, for procedures depending on the outcome of the RZ.

  • •

    Follow SI 04040.010G to reinstate the pending Title XVI hearing appeal.

  • •

    Reinstate SBC payments as of the month the AC remanded the case to the hearing level.

  • •

    For Title II, follow DI 12027.060. Reminder: For Title II auxiliaries, obtain their own SBC elections.

If contact is received more than 15 days after the date of the hearing office notice, obtain SBC election and develop for good cause per GN 03101.020. If good cause is found, follow the steps above.

Contacts the FO to request SBC payments prior to the FO processing the AC remand notification:
  • •

    Query the Supplemental Security Record (SSR) and Master Beneficiary Record (MBR).

  • •

    Locate a copy of the remand order in eView.

  • •

    Follow SI 04040.010G to reinstate the pending Title XVI hearing appeal.

  • •

    Request the individual submit their SBC election in writing.

  • •

    For electronic cases, scan the signed election statement into section E of the electronic folder (EF). Verify the document is in the EF and shred the original per DI 81020.055.

  • •

    For paper cases, scan the signed election statement into the Evidence Portal (EP).

  • •

    Process the RZ for non-disability Title XVI factors.

  • •

    For Title XVI, reinstate payment at the PPL effective as of the month of the AC remand order if the non-disability factors permit payment (see SI 02301.325).

  • •

    Do not reinstate payments if non-disability factors do not permit payment and notify the

    individual of their ineligibility to receive SBC.

  • •

    For Title II, if all eligibility requirements are met to reinstate SBC payments, follow DI 12027.060C.

4. SBC reinstatement date

Reinstate SBC upon AC remand in accordance with the following chart. For Title XVI SBC input instructions see MS 00302.020.

If the individual:

Then:

Received SBC until the ALJ decision:

For Title XVI, if eligible for continued payments, reinstate payment continuation retroactive to the first month of non-payment resulting from the now vacated ALJ decision.

For Title II, follow DI 12027.060.

NOTE: Windfall offset applies whenever retroactive SBC payments are due for both Title II and Title XVI in the same month. See GN 02610.016.

Did not elect SBC or requested SBC late at the prior ALJ level and good cause was not found:

For Title XVI, if eligible for continued payments, and is requesting SBC after the AC remand, reinstate as of the first day of the month of the AC remand order.

For Title II, follow DI 12027.060A.

Previously submitted a late SBC request and a good cause determination was not made but good cause is found now.

If eligible for continued payments, reinstate payment continuation retroactive to the first month of non-payment resulting from the reconsideration determination. Document the good cause finding and determination following DI 12027.008B.1.

D. Effectuating the ALJ decision after an AC remand

Process the new ALJ decision after AC remand in accordance with the following chart:

If the claim is:

Then:

Approved (e.g., ALJ issues favorable decision after the AC remand):

Update the Title XVI record with the cessation reversal and effectuate ongoing payments. For Title II, the processing center (PC) will process the ALJ decision and effectuate the ongoing payments.

Denied, closed period, or dismissed:

Upon notification from the hearing office, the FO will terminate benefits. SBC ends the month before the month of the ALJ decision or dismissal date.

For closed period or unfavorable decisions or dismissals, the hearing office will add the following language to the decision transmittal: "Further action necessary by claims processing component. The individual in this medical cessation case appears to have had disability payments/benefits continued through the hearing level. The ALJ's decision/dismissal of (date) is less than fully favorable; disability ceased on (date). Please terminate continued disability payments/benefits immediately."

For electronic cases, this information will be viewable under the Case Data tab in eView. For paper cases, the hearing office will send a copy of the decision/dismissal and transmittal to the FO via desktop fax.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0412027065
DI 12027.065 - Title XVI and Concurrent Title II/Title XVI Statutory Benefit Continuation When the Appeals Council Remands a Medical Cessation Case to the Hearing Level - 03/26/2025
Batch run: 03/26/2025
Rev:03/26/2025