DI 13010.012: Protection from Medical Review Based on Work Activity

changes
←	*	→

~~Effective Dates: 06/29/2017 - Present~~
Effective Dates: 04/18/2018 - Present
TN 27 (04-09)
DI 13010.012 Protection from Medical Review Based on Work Activity
A. Background
Section 111 of P.L. 106-170, The Ticket to Work and Work Incentives Improvement Act of 1999, added this provision to section 221(m) of the Social Security Act (effective January 1, 2002),
The work incentive, “Protection from Medical Review Based on Work Activity” provides:
* Long-term Title II disability beneficiaries the option to return to work by ensuring work activity alone will not trigger a medical Continuing Disability Review (CDR).
* Beneficiaries who are entitled to Title II, or concurrently entitled to both Title II and Title XVI benefits for at least 24 months will not have a medical CDR triggered solely as a result of his or her work activity.
NOTE: If a beneficiary qualifies for protection from medical review based on work activity, he or she will still undergo regularly scheduled medical CDRs, and to any other medical CDRs that are initiated for a reason(s) other than the beneficiary’s work activity, unless the individual is “using a ticket” under the Ticket to Work program.
See Also:
DI 13001.005- Events Which May Initiate a CDR
DI 55025.001- Ticket to Work
B. Determining protection from a medical review
1. Field offices (FOs) and processing centers (PCs)
Screen work CDR cases to determine whether an individual qualifies for the protection from a medical review based on work activity using eligibility requirements in DI 13010.012C in this section; if the protection applies, defer the medical CDR. However, if the protection does not apply, continue processing the medical CDR (see DI 13010.010 for events that may initiate a work CDR).
2. Disability Determination Services (DDS)
Follow CDR processing procedures using the Medical Improvement Review Standard (MIRS)-see DI 28005.005.
C. Policy - eligibility requirement for an individual to be entitled to protection from a medical review
Effective with work determinations made on or after December 18, 2006, the criteria below must be met:
1. Meets the 24-month requirement
* A Title II disability beneficiary (including a beneficiary concurrently entitled to Title II and Title XVI benefits based on disability and or blindness) must have received Title II disability benefits for at least 24 months; the 24 months do not have to be consecutive.
* Months that the beneficiary actually received Title II disability benefits that he or she was due will count for the 24-month requirement, as well as months that the beneficiary constructively received such benefits.
* If we withheld a benefit payment to recover an overpayment, we will consider that the beneficiary constructively received a benefit for purposes of the 24-month requirement.
* For Title II expedited reinstatement (EXR) cases, we consider the 24-month requirement to be met when the beneficiary completes the 24-month initial reinstatement period (IRP).
2. Does not meet the 24-month requirement
Any month that the beneficiary was entitled to Title II disability benefits, but for which the beneficiary did not actually or constructively receive a benefit payment, will not count for the 24-month requirement:
In addition, we do not consider the 24-month requirement for months an individual:
* is in prisoner suspense;
* is receiving Medicare Qualified Government Employment (MQGE) wages;
* is in full workers compensation offset;
* is a disabled adult child (CDB) technically entitled to a disability maximum (DMAX);
* received benefits due to a pending appeal of a medical cessation (statutory benefit continuation); or
* is or was a concurrently entitled Title II and Title XVI beneficiary who received only Title XVI payments.
See Also:
DI 12027.001- Statutory Benefit Continuation
DI 13005.060 – Processing MQGE Wages
3. When the 24-month requirement is met and protection begins
The individual must have met the 24-month requirement on the first day of the first month following the 24th month that the individual actually (or constructively) received Title II disability benefits that he or she was due.
The date we start a CDR will be the date on the notice we send to the beneficiary that explains that we are beginning the medical continuing disability review.
NOTE: If the beneficiary does not meet the 24-month requirement for the first medical CDR that is triggered by work activity; he or she may meet the requirement for future CDRs. Once a beneficiary has qualified for the protection from medical review based on work activity, the protection continues until the end of that period of disability entitlement.
4. Use of eWork in determining eligibility requirement
The eWork program assists adjudicators in the determination of whether a beneficiary qualifies for the protection from a medical review based on work activity. However, the final determination rests solely with the adjudicator, after considering all pertinent data. If the adjudicator agrees that as indicated on the eWork Case Summary Checklist that ODO/PSC should conduct a medical file review, fax the eWork generated SSA-882 to PC Paperless to alert the PC that this action should be taken. For detailed phone, fax, and address information for the PCSs, go to the following link: http://kcnet.kc.ssa.gov/psc_contacts/index.htm.
D. Procedure - when “protection from medical review based on work activity” applies
1. Background
When a beneficiary is initially approved (and in subsequent disability reviews) for disability, we establish a medical improvement diary. Depending on the type of medical improvement diary, work activity can prompt a medical review before the regularly scheduled diary date.
For a concurrently entitled Title II and Title XVI beneficiary, if the medical CDR is deferred on the Title II portion, the deferral also applies for Title XVI; this includes 1619 initial eligibility and 1619 status change CDRs. An exception to work activity prompting a medical improvement review may apply if the beneficiary is participating in the Ticket to Work program (see DI 55025.000).
2. Types of Medical Improvement Diaries
The types of diaries are: Medical Improvement Expected (MIE), Medical Improvement Possible (MIP), and Medical Improvement Not Expected (MINE).
* MIE Diary: Query the Query Medical Information Data (QMID) screen of the Disability Control File (DCF) to view the Medical Re-Exam Date and Reason codes. The medical diary information may be on the SSA-831, or on the National Disability Determination Services System (NDDSS). An alpha code in the Medical Re-Exam Reason field indicates an MIE diary.
* MIP Diary: Query the QMID screen under the DCF to view the Medical Re-Exam Date, Medical Re-Exam Reason and Disability Permanent codes. The medical diary information may be on the SSA-831, or on the NDDSS. A “3” in the Medical Re-Exam Reason field and an “N” in the Disability Permanent field indicates a MIP diary.
* MINE Diary: Query the QMID screen under the DCF to view the Medical Re-Exam Date, Medical Re-Exam Reason and Disability Permanent codes. The medical diary information may be on the SSA-831, or on the NDDSS. A “5” or “7” in the Medical Re-Exam Reason field and a “P” in the Disability Permanent field indicates a MINE diary.
See Also:
DI 13005.005 – Medical Improvement Diaries
3. Procedure for MIE diaries
If the Beneficiary has a MIE diary, and...
And Protection from Medical Review...
Then...
Reports SGA or Non-SGA level work
Does Apply
Defer the medical CDR, and document work activity, see DI 13010.020.
Does Not Apply
Document work activity based on instructions found in DI 13010.000. Perform medical file review process (DI 40510.040) and if medical CDR is needed follow instructions in DI 13005.025 for initiating the CDR.
Is selected for a medical review or has a matured medical diary
Does or Does Not Apply
Screen out cases according to instructions in DI 13005.020 or DI 28003.005.
If CDR is needed, follow instructions in DI 13005.025 for initiating the CDR
The beneficiary or a 3rd party reports medical improvement
Does or Does Not Apply
Follow instructions in DI 13005.000 to initiate the medical CDR.
Submits additional evidence which raises a medical CDR issue. (See DI 13001.005I.)
Does Apply
Follow instructions in DI 13005.000 for initiating the CDR—only if information pertains to medical evidence.
Does Not Apply
Follow instructions in DI 13005.000 for initiating the CDR.
4. Procedure for MIP and MINE diaries:
If the Beneficiary has a MIP or MINE diary, and...
And Protection from Medical Review...
Then...
Reports SGA or Non-SGA level work
Does or Does Not Apply
Document work activity based on instructions found in DI 13010.000. Establish diary for TWP.
Is selected for a medical review or has a matured medical diary
Does or Does Not Apply
Screen the cases according to instructions in DI 13005.020 or DI 28003.005.
If CDR is needed, follow instructions in DI 13005.025 for initiating the CDR
Completes TWP
Does Apply
Defer the medical CDR, and document the TWP, per DI 13010.090.
Does Not Apply
Perform medical file review process (DI 40510.040), and if medical CDR is needed, follow instructions in DI 13005.000 for initiating the CDR.
The beneficiary or a 3rd party reports medical improvement
Does or Does Not Apply
Follow instructions in DI 13005.000 to initiate the medical CDR.
Submits additional evidence which raises a medical CDR issue. (See DI 13001.005I.)
Does Apply
Follow instructions in DI 13005.000 for initiating the CDR—only if information pertains to medical evidence.
Does Not Apply
Follow instructions in DI 13005.000 for initiating the CDR.
E. Procedure - deferring the medical CDR when the “protection from medical review based on work activity” applies
* Defer the medical CDR until an event prompts a medical CDR for reasons other than work activity. For example: the regularly scheduled medical diary is selected for review, or the individual or a third party reports medical improvement
* Annotate the remarks section of the Cessation or Continuance of Disability or Blindness Determination and Transmittal (SSA-833), the Continuing Disability Review (SSA-899) or the DO Report of Field Review of Continuing Disability (SSA-882) with “Protection from medical review based on work activity.” For instructions on how to complete the SSA-833, see DI 13010.170. For instructions on how to complete the SSA-899, see DI 13010.175.
NOTE: eWork prints the remark on the SSA-833 and on the DCF for all medical review protection cases.
* Post a remark on the CDR Remarks Input (IRMK) screen of the DCF (MSOM CDR 001.009): “Medical CDR deferred due to Protection from Medical Review based on Work Activity,” and record the date of the determination.
* For a Title II file in the FO, follow national procedure for sending the folder to storage until:
* the regularly scheduled medical diary matures, or
* the individual alleges medical improvement, or
* any other event occurs that would prompt a medical CDR for a reason other than the beneficiary’s work activity.
* For electronic processes, follow procedure in DI 81010.000.
References:
DI 13005.055 – Processing Possible Medical Recoveries in the FO
DI 40505.115 – Voluntary Report of Medical Improvement (MI)
DI 40505.120 – Third Party Reports
F. Protection from medical review applies – statutory blindness case needs a DDS determination
Even though the beneficiary qualifies for protection from a medical review based on work activity, the following cases involving statutory blindness should be forwarded to DDS for a determination. If medical improvement is found, the case may be medically ceased:
Even though the beneficiary qualifies for protection from a medical review based on work activity, the following cases involving statutory blindness should be forwarded to DDS for a determination:
* Insured status issue - a substantive determination on the issue of blindness required;
* Individual is engaging in SGA, alleging visual impairment, and statutory blindness has not been established;
* Comparable work decision where the FO finds SGA for blind DIB, CDB, or DWB claimants, age 55 or older;
* Statutory blindness determination required for under age 55 DWB and CDB claimants where FO finds SGA at the non-blind level.
See Details:
DI 26001.010 – Jurisdiction of Blindness Cases
G. Procedure - beneficiary protests the start of a medical CDR
The CDR come-in letter will inform the beneficiary that we may not conduct the medical review if:
* he or she has received Social Security disability benefits for at least 24 months, and the reason for the review is because of his or her work activity, or
* if he or she is using a ticket under the Ticket to Work program
The letter will offer an opportunity to protest the start of the review if he or she believes that either condition applies. If the beneficiary contacts the FO, and it is determined that the CDR was initiated in error:
* discontinue processing the medical CDR; and
* input a stop CDR decision on the DCF using the CDR FO Input (IFOA) screen.
1. Electronic process
An automated process is used when we select electronic CDRs; they are controlled by the DCF. If it is determined that a medical CDR is not appropriate, and the CDR is electronic, further electronic development is unnecessary, however, you still must close the pending medical CDR in the DCF, and explain why you stopped the CDR.
See Details: DI 81010.205 - Electronic Continuing Disability Review (eCDR) Case Selection
2. Non-electronic cases
a. Folder is in the FO
* Send the CDR deferral notice (see notice language (NL 00705.355).
* Clear the CDR using the STOP CDR option on the IFOA screen if the system has not closed the CDR.
* Enter a dated remark on the CDR Remarks Input (IRMK) screen, and explain that you stopped the CDR because the beneficiary is eligible for the protection from medical review based on work activity.
* Follow national procedures for sending the folder for storage.
b. Folder at DDS
* If the folder is in the DDS (and a CDR decision has not been issued) the FO will contact the DDS, and tell them to clear the case as a “no decision case.”
* Send the CDR deferral notice in NL 00705.355 and if it has not been cleared by the system, clear the CDR in DCF with the STOP CDR option on the IFOA screen.
* Enter a dated remark on the IRMK screen explaining that you stopped the CDR because the beneficiary is eligible for the protection from medical review based on work activity
* Follow national procedures for sending the folder for storage.
See Also:
DI 55025.000 The Ticket to Work program.
National Records Center – Shipping Non-Actionable Folders to the National Records Center (NRC)
H. Policy - medical cessation: medical review protection not applied
If a medical cessation has been effectuated, discontinue the medical cessation, and reinstate benefits if:
* the beneficiary provides evidence within 12 months from the date of the notice of the initial determination of medical cessation, and
* the evidence establishes that we started the medical review in error because he or she was eligible for the protection from medical review based on work activity.
If we cleared the CDR event in the DCF as a cessation, you will see a Modify Medical Data screen (MMDS) screen with zeroes, and a comparison point decision (CPD) date from the date of the cessation:
* Use the MMDS to re-establish the correct medical information in the DCF. Over-key the zeroes with the information contained on the previous MMDS screen in order to re-establish the medical information, the previous CPD date and the diary (for more information on these screens, see MSOM CDR 001.017 and DI 13010.640).
* Enter a dated remark on the IRMK screen explaining the cessation decision has been vacated because the beneficiary was eligible for the protection from medical review based on work activity.
1. Title II cases
Follow the procedures outlined in DI 13010.197C to reinstate benefits retroactively to the date of the termination action that was based on the cessation determination resulting from the erroneous start of the CDR. Contact the PC/OCO for reinstatement of benefits and Medicare.
2. Concurrent Title II and Title XVI cases
* If the medical issue (MG) field on the Supplemental Security Income Record (SSR) indicates a code of T, input the SSI reinstatement and update the MG field via MISSICS, and line through the paper Cessation or Continuance of Disability or Blindness Determination and Transmittal (SSA-833-U3) and/or 832 (Title XVI), if appropriate. Enter in the remarks section “decision vacated because the beneficiary was eligible for the protection from medical review based on work activity.”
* If the cessation decision is under appeal, recall the folder from the Office of Disability Adjudication and Review (ODAR). If the beneficiary elected statutory benefit continuation, contact the PC/OCO to correct the record for Title II and or correct the SSR through direct input for Title XVI.
* The FO reactivates the case, and sends it back to the DDS for the determination to be vacated. The DDS will document the DDSQ as a “no determination.” For more information on how the FO should vacate a CDR medical cessation determination, see DI 13015.300.

POMS Reference

DI 13010.012: Protection from Medical Review Based on Work Activity