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DI 12027.020: Determining Statutory Benefit Continuation (SBC) Payment Months

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  • Effective Dates: 11/16/2009 - Present
  • Effective Dates: 05/20/2018 - Present
  • BASIC (10-06)
  • DI 12027.020 Determining Statutory Benefit Continuation (SBC) Payment Months
  • A. Policy – SBC Payment Months
  • 1. Reconsideration Level
  • If there is a timely election of SBC when a reconsideration is requested, payments will begin with the first month of non-payment following the initial disability cessation (or adverse medical reopening/revision determination).
  • 2. Administrative Law Judge (ALJ) Level
  • If a beneficiary does not elect SBC at the reconsideration level, but does elect SBC at the ALJ hearing level, reinstated payment will be effective with the later of:
  • * The month of the reconsideration determination notice; or
  • * The month of election.
  • 3. Appeals Council (AC) Remand
  • For AC remand cases:
  • * See DI 12027.060 for information about reinstating benefits in Title II cases.
  • * See DI 12027.065 for information about reinstating benefits in Title XVI and concurrent Title II/Title XVI cases.
  • NOTE: See SBC Election of Medicare-Only, DI 12027.035 for Medicare-Only SBC month(s) information.
  • B. Policy – The Last Month of SBC Payment
  • The last month of elected SBC payment is through the earlier of:
  • * The month before the month of the ALJ decision, or the month before the month of a new ALJ decision (or final action by the AC on an ALJ's recommended decision) if the AC remands the case to an ALJ for further action; or
  • * The month before the month in which no timely request for reconsideration or an ALJ hearing is pending.
  • EXAMPLE:
  • * Remy’s cessation month is July 2006.
  • Her termination month would be October 2006.
  • * Remy filed a timely request for an appeal and SBC in July 2006.
  • SBC begins in October 2006.
  • * An unfavorable reconsideration determination was made in October 2006.
  • NOTE: If Remy does not appeal to the ALJ, December is the last month of SBC payment. (See DI 12027.020B.2.)
  • The SBC months of October through December are overpayments.
  • * However, Remy does file a timely request for both an ALJ hearing and SBC in November 2006, so SBC will continue.
  • * If the ALJ decision, made for example in June 2007, is unfavorable, the last month of SBC payment will be May 2007. (See DI 12027.020B.1.)
  • Any SBC payment(s) paid to Remy after May 2007 are overpayments.
  • C. SBC Termination Month - Notification of Determination, Decision or Dismissal of Appeal
  • 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 Office of Disability Adjudication and Review/Hearing Office (ODAR/HO) about the appeal determination, decision or dismissal.
  • 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:
  • * When the appeal determination/decision by DDS or HO is favorable, the FO will terminate SBC payments and reinstate regular payments.
  • * 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.
  • * See The Last Month of SBC Payment, DI 12027.020B.
  • * See Waiver Provisions for Title II and Title XVI Overpayments, GN 02250.000.
  • 1. Reconsideration Level
  • * The DDS will input an unfavorable determination on the appeal.
  • * The system will automatically terminate SBC based on the data from the DDS input for Title XVI cases.
  • * 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.
  • 2. ALJ Hearing Level
  • * The HO will input an unfavorable decision on the appeal (or dismissal of the request for an ALJ hearing).
  • * The system will automatically terminate SBC based on the information from the HO input for Title XVI cases.
  • * 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:
  • * Claim type – HA
  • * Case input by HO within 30 days of the ALJ decision
  • * Decision is unfavorable
  • * Hearing type indicates SBC is involved, and
  • * 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
  • * See DI 12027.060 about processing SBC in AC remands of Title II cases.
  • * See DI 12027.065 about processing SBC in AC remands of Title XVI or concurrent Title II/Title XVI cases.
  • D. Policy – SBC Payment Month Overpayments
  • * SBC payments are overpayments if the appeal is unsuccessful.
  • * By law, the individual must appeal the medical cessation in good faith to be offered waiver consideration. If the individual does not appeal in good faith, do not offer waiver consideration. The FO must consider any physical, mental, educational, or linguistic limitations in determining good faith.
  • * For instructions on processing requests for waiver of recovery of overpayments in disability cessation appeal cases with SBC involvement see:
  • * Waiver Provisions for Disability Cessation Cases, SI 02260.007
  • * Payment Continuation – Waiver Title II, XVI, GN 02250.036
  • E. Policy - Workers’ Compensation (WC) Payments
  • * If the claimant is receiving SBC and WC payments at the same time, then the current rules regarding WC offset apply.
  • * When electing SBC, if WC offset applies to benefits at the time of cessation, continue applying WC offset and make adjustments as if the individual were receiving regular disability (DIB) payments.
  • * If WC is first received during the SBC period, offset will begin at that time as if the individual were receiving regular disability (DIB) payments.
  • See Offset Provisions, DI 52101.001 regarding workers' compensation offset.
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