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Continuing Disability Reviews Process

Expedited Reinstatement

HUD Requirements

Overpayments

Statement of Sue Augustus

 

 

EXPEDITED REINSTATEMENT OF BENEFITS POLICY
WHO CAN BE REINSTATED EFFECTIVE JANUARY 1, 2001–

For Social Security Disability Insurance (SSDI), Disabled Widow/er and Disabled Adult Child beneficiaries:

  • If individual was receiving SSDI, Disabled Widow/er benefits, or Disabled Adult Child benefits and those benefits were stopped due to earnings over Substantial Gainful Activity (SGA); and
  • The individual is no longer able to perform SGA due to a disabling impairment which is the same as or related to the impairment that was the basis for their previous disability entitlement; and
  • The request for Expedited Reinstatement is made within 60 months of the month of benefit termination.

If the individual does not apply within the 60 month period, individual can argue that he/she has good cause for late filing.

For Supplemental Security Income (SSI) beneficiaries:

  • If individual was receiving SSI benefits and those benefits were terminated because of excess earned income or a combination of earned and unearned income; and
  • The individual is no longer able to perform SGA due to blindness or disability, which is the same as or related to the impairment that was the basis for their previous SSI eligibility; and
  • The request for Expedited Reinstatement is made within the consecutive 60 month period beginning with the month of benefit termination.

If the individual does not apply within the 60 month period, individual can argue that he/she has good cause for late filing.

 

PROVISIONAL BENEFITS

For Social Security Disability Insurance (SSDI), Disabled Widow/er and Disabled Adult Child beneficiaries:

An individual who requests Expedited Reinstatement and meets the requirements described above, may receive up to 6 months of provisional cash benefits.
Provisional benefits are not payable to previously entitled auxiliaries and any potential auxiliary claimants, other than a previously entitled Disabled Widow/er Beneficiary or Disabled Adult Child claimant who is eligible and requests Expedited Reinstatement. Provisional benefits are not payable for an individual requesting Expedited Reinstatement of Disabled Adult Child benefits on the record of a number holder who is living, if the number holder is not currently entitled.

Provisional Benefit amount
The amount of the provisional benefit is the amount of the last monthly benefit payable, increased by the intervening cost of living increases plus adjustments due to earnings since the prior termination. If an offset was applied before the prior termination, then the offset will be continued during the provisional benefit period.

Starting month for Provisional Benefits
Beginning the month the individual files the Expedited Reinstatement request, but no earlier than 1/1/01. Provisional Benefits can be paid during a consecutive 6 month period beginning the month the Expedited Reinstatement request is filed.

Ending Month of Provisional Benefits

The earliest of:

  • The month SSA makes a determination and issues the notice regarding the ER request; or
  • The month the individual works and performs SGA; or
  • The month the individual attains full retirement age; or
  • The 5th month following the month the individual filed the ER request.

For Supplemental Security Income (SSI) beneficiaries:
An individual and eligible spouse who requests and meets the requirements may receive up to 6 months provisional cash benefits. The amount is the amount that the individual would receive with the same kinds of income and living arrangements. No state supplementation is included in the provisional benefit.

Resources are not developed nor considered when determining eligibility for, and amount of provisional benefits. However, resources are considered when determining eligibility for reinstatement. Ineligibility for SSI due to resources or any other reason also means that the individual is ineligible for provisional payments. If the individual has a spouse who may be eligible for SSI, the provisional payment is based on a couple’s computation. If the spouse would be eligible based on blindness or disability, a medical review will be required for the spouse.

Provisional payments will begin with the month after the month the individual files the reinstatement request. In most states, (although not automatically in Illinois), eligibility for provisional payments also allows the person to be reinstated for Medicaid benefits.

 

REINSTATEMENT

If SSA determines that the individual who requested Expedited Reinstatement does not meet the reinstatement requirements, the Expedited Reinstatement request is denied. Provisional payments will be stopped. If SSA determines that the individual is not under a disability based on the medical improvement review standard, then a notice will be sent. This decision is appealable. Generally, any provisional benefits paid are not an overpayment. However, see overpayment section.

For Social Security Disability Insurance (SSDI), Disabled Widow/er and Disabled Adult Child beneficiaries:

If DDS determines that the individual is disabled based on the medical improvement review standard, reinstatement of Title II can be made retroactively for up to 12 months before the Expedited Reinstatement request was made (but not for months before 1/1/01) provided all other factors of entitlement are met. Any months of SGA will not be paid. Any months that the individual did not work for reasons other than his/her disabling impairment also will not be paid. Benefits for auxiliaries who were previously entitled and continue to meet entitlement requirements can also be reinstated as far back as the number holder.

After an individual receives 24 months of, not necessarily consecutive, reinstated benefits (which includes the provisional benefit period and any period of retroactivity), SSA may deem that the Expedited Reinstatement request is a new disability application for the following purposes:

  • Entitlement to a new 9 month trial work period;
  • Entitlement to a new 36 month extended period of eligibility;
  • Entitlement to a new 60 month Expedited Reinstatement request period if the reinstated benefits terminate due to SGA earnings.
  • Entitlement to reinstated benefits end the month before the earliest of:
  • The 3rd month following the month SSA determines that the individual’s disability has ceased due to either SGA or medical improvement; or
  • The month in which the individual attains full retirement age; or
  • The month in which the individual dies.

For Supplemental Security Income (SSI) Beneficiaries:

If SSA determines that an individual who requested Expedited Reinstatement does not meet the reinstatement requirements, Expedited Reinstatement is denied. If individual is found not disabled, the disability decision may be appealed but the provisional payment determination may not be appealed. Any provisional payments made are not an overpayment. The request for reinstatement will be used as protective filing for a new SSI application if the individual chooses to file.

If the individual is found disabled, reinstated payments may be made. Payment should begin at the later of 2/1/01 or the month after the month the individual requested reinstatement. The reinstated benefits will be adjusted to reflect the amount of the provisional payments. After an individual receives 24 months (not necessarily consecutive) of reinstated benefits, SSA may deem that the request for reinstatement is a new application for purposes of requesting expedited reinstatement if SSI eligibility terminates after a subsequent period of ineligibility due to excess earned income.

Actions to pay, adjust or terminate provisional benefits are not initial determinations that are subject to the administrative or judicial review process. This means that the local SSA office has the final decision on these issues. Disability determinations, and overpayment decisions, however, are appealable through the normal appeals process.

 

PROTECTIVE FILING

For SSDI, Disabled Widow/er, Disabled Adult Child and SSI beneficiaries, SSA may use the date a claimant first contacts SSA (either verbal or written) as the filing date of the request for expedited reinstatement. The Expedited Reinstatement filing date can also be used to protect the filing date of a new application if the individual decides not to pursue filing for expedited reinstatement, or if the request for reinstatement is denied and the claimant wishes to have the request treated as an application.

An individual has 60 days to file a signed request for Expedited Reinstatement after making a verbal request to file.

 

SUSPENSION/TERMINATION OF PROVISIONAL BENEFITS

Such suspension events include prisoner suspension, alien suspension, etc. Marriage, under certain circumstances of a Disabled Widow/er Benefit or Disabled Adult Child will terminate the Provisional Benefits. Provisional Benefits will not resume if suspension or termination event continues beyond occurrence of any of the ending events listed above.

 

MEDICARE ELIGIBILITY FOR SSDI, DISABLED WIDOW/ER, DISABLED ADULT CHILD

If individual already has extended Medicare coverage, it will continue. If individual has Part A only, he/she can elect Part B coverage during a general enrollment period or special enrollment period that occurs during the provisional period. If the individual has both A and B, both will continue at same rate for B. If the individual has extended Medicare coverage that ends during the provisional period, it will continue until end of provisional benefit period.

If individual is paying for Part A, there is no premium for Part A during the provisional period. If the individual had no Medicare coverage, then either A or A and B will be reinstated. If beneficiary attains age 65 during provisional period, then Medicare will convert to Aged Medicare.

Effect of Medicare termination when provisional benefit period ends:

If provisional benefit period ends, but decision regarding reinstatement has not been made, Medicare will end with the earliest of the following: Last day of the month following the notice of termination of provisional payments due to SGA; or last month of the provisional benefit period.
Medicare will not end if the individual is still in the extended period of Medicare or entitled to it on the basis of age or End Stage Renal Disease.

If Disability Determination Service finds an individual is disabled based on the Medical Improvement Review Standard and the individual is reinstated for benefits, he/she has a new period of benefit entitlement for Medicare purposes w/a new enrollment period for Part B. Part A can begin earlier if disability benefits are due retroactively.

If individual did not have Medicare or had extended Medicare which ended during the provisional benefit period and DDS finds the individual no longer under a disability, Medicare coverage will stop at the earliest of the end of the month following the reinstatement denial notice is mailed, or the end of the 6 month provisional period. If the individual had extended Medicare, which would have continued beyond the provisional benefit period, Medicare coverage will end the last day of the month following the month the notice of disability determination is mailed.

 

WHAT IS AN EXPEDITED REINSTATEMENT OVERPAYMENT?

The amount of provisional benefits paid after the date the beneficiary is told benefits will end.

The amount paid to a beneficiary who provided false statements or misrepresented the facts to receive benefits.

The incorrect amount paid in provisional payments that is discovered when adjustment action is taken to reinstate benefits.

The amount or incorrect amount of title II or Title XVI provisional benefits paid for any month when benefits should have been adjusted or stopped because of SGA.

A finding that the prior termination was for medical improvement will result in an overpayment of any provisional benefits already received.

Waiver of the overpayment may be requested either orally or in writing. Reconsideration request must be in writing.

 

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