DI 13010.135: Title II Continuing Disability Considerations in Blindness Cases

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~~Effective Dates: 09/21/2016 - Present~~
Effective Dates: 01/05/2018 - Present
TN 37 (11-15)
DI 13010.135 Title II Continuing Disability Considerations in Blindness Cases
A. Office of jurisdictions for processing work continuing disability review (CDR) for blind beneficiaries
The Social Security Act (Act) contains several special provisions for disability beneficiaries who meet the definition of blindness. Because of these special provisions, the Office of Disability Operations (ODO) and the Program Service Center Disability Processing Branches (PSC DPB) in PSCs 1-6 have greater responsibility in the processing of continuing disability review (CDR) cases involving blindness and has jurisdiction for all work CDRs for statutorily blind beneficiaries age 55 and older. Follow instructions in this chapter to process work CDRs for blind beneficiaries.
NOTE: The ODO Disability Processing Branch (DPB) in PC7 workload consists of initial claims only. For routing work CDRs to PC7, follow instructions in DI 13010.025.
B. Determining if a beneficiary is statutorily blind
To determine if a Title II beneficiary meets the statutory definition of blindness, review all of the following:
* The SSA-831-U3 (Disability Determination And Transmittal) in eView for a diagnosis code of 3694, or an entry of “statutory blindness” in Item 16A, entry of A1 in Item 22, and codes 2.02 or 2.03a in Item 23;
* The Query Medical Information Data (QMID) or Query Modify Medical Data (QMMD) screen of the Disability Control File (DCF) for a listing code of 2.02 or 2.03A, and a code of A1 in the REG field;
* The Disability Determination System Query (DSQ) shows a listing code of 2.02 or 2.03A, and a residual functional capacity (RFC) code of 30 (T2) or 70;
* The SSA-831-U3 (Disability Determination And Transmittal) in eView for a diagnosis code of 3694, or an entry of “statutory blindness” in Item 16A, entry of A1 in Item 22, and codes 2.02 or 2.03a (or listing 2.03B prior to 2/20/2007) in Item 23;
* The Query Medical Information Data (QMID) or Query Modify Medical Data (QMMD) screen of the Disability Control File (DCF) for a listing code of 2.02 or 2.03A (or listing 2.03B prior to 2/20/2007), and a code of A1 in the REG field;
* The Disability Determination System Query (DSQ) shows a listing code of 2.02 or 2.03A (or listing 2.03B prior to 2/20/2007), and a residual functional capacity (RFC) code of 30 (T2) or 70;
* The Medical Listing Number (MLN) field for codes 2.02 or 2.03A and the Basis Code (BAS) field for A1, or an entry of Y in the Stat Blind Indicator (SBI) field of the DDSQ;
* A date in the Adjusted Blind Onset Date (ABOD) field in the Benefit Data Line, of the Master Beneficiary Record (MBR); or
* The Disability Award Code (DAC) for L, N, P, S, and T on the disability insurance benefits (DIB) line of the MBR.
NOTE: The diagnosis (DIG) code of 3690 alone does not mean that a beneficiary meets the statutory definition of blindness. We use the DIG code of 3690 to describe any visual impairment. When a beneficiary meets the criteria for blindness as described in the Act, the disability determination impairment code is 3694 (effective December 1, 2012), and shows the statutorily blind person meets listing code 2.02 or 2.03A.
NOTE: The diagnosis (DIG) code of 3690 alone does not mean that a beneficiary meets the statutory definition of blindness. We use the DIG code of 3690 to describe any visual impairment. When a beneficiary meets the criteria for blindness as described in the Act, the disability determination impairment code is 3694 (effective December 1, 2012), and shows the statutorily blind person meets listing code 2.02 or 2.03A (or listing 2.03B prior to 2/20/2007).
C. Evaluating work activity for blind beneficiaries
We use different substantial gainful activity (SGA) earnings guidelines to evaluate the work activity performed in 1978 or later by blind Title II beneficiaries. For a table of SGA earnings guidelines, see DI 10501.015.
For blind beneficiaries who are self-employed, use only the countable income test to determine if the self-employment represents SGA. For complete information on evaluating work activity for SGA and the countable income test see DI 10515.001through DI 10515.015.
D. Applying trial work period (TWP) and extended period of eligibility (EPE) for blind beneficiaries
The TWP and EPE provisions apply to blind beneficiaries with the following exceptions:
Although cash benefits for blind beneficiaries may end due to the performance of SGA after the EPE, and Medicare may terminate under the normal rules regarding extended Medicare, the period of disability continues. The beneficiary will be in a disability freeze status. Since there can be only one TWP in a period of disability, the beneficiary is not entitled to another TWP if SGA subsequently stops and he or she returns to benefit status through a new claim in the DIB attainment process.
For details on:
* entitlement to TWP see DI 13010.035C.2.; and
* DIB attainment processes see DI 13010.135K.
Blind beneficiaries age 55 and older may be entitled to disability while engaging in non-comparable SGA, for policy for statutorily blind individuals age 55 and older see DI 13010.135F in this section. A beneficiary who becomes entitled while performing non-comparable SGA is not eligible for a TWP unless:
* he or she returns to SGA that requires skills or abilities comparable to those required in the work he or she performed before the onset of blindness or age 55, whichever is later; or
* his or her previous work ended due to impairment, the current work requires a significant vocational adjustment; and
* he or she has not previously had a TWP in the same period of disability. (For entitlement to TWP see DI 13010.035C.2.)
E. Processing work CDRs for blind beneficiaries
Use eWork to develop and control work CDRs for blind beneficiaries. However do not use eWork to process a work determination if the beneficiary is age 55 and older, or not entitled to a TWP based on one of the exceptions in DI 13010.135D in this section. The Office of Central Operations and Program Service Centers maintains jurisdiction for all work CDRs for blind beneficiaries age 55 and older, and all determinations that cannot process through eWork.
F. Policy for statutorily blind individuals age 55 and older
To meet the definition of statutory blindness for individuals age 55 to full retirement age, we define disability as “the inability by reason of such blindness to engage in SGA requiring skills or abilities comparable to those of any SGA in which the individual engaged prior to onset of blindness or age 55, whichever is later.” The Disability Processing Branch in PSCs 1-6 maintain jurisdiction for all work CDRs for statutorily blind beneficiaries age 55 and older, and is responsible for making the comparability determination.
If the field office (FO) receives a work report for a statutorily blind DIB, DWB or childhood disability benefits (CDB) beneficiary who is age 55 and older,
* Establish the case in eWork, as Stat Blind, Obtain an SSA-821-BK (Work Activity Report-Employee) or SSA-820-BK (Work Activity Report for Self-Employed Person) to document all work activity from the later of age 55 or the onset of blindness, to the present.
* Upon completing the development, fax all material into the electronic folder (EF) or into the Non Disability Repository for Evidentiary Documents (NDRED) if there is no EF. Do not prepare a determination or suspend benefits.
* Transfer eWork and the DCF to the PC of jurisdiction. Be sure to transfer both eWork and DCF; your open DCF event establishes the Action Control Record (ACR) for the PC, if an ACR is not already established.
Work CDR processing for statutorily blind beneficiaries age 55 and older:
If beneficiary:
and then:
the beneficiary is:
was already entitled prior to age 55, is now statutorily blind and age 55 or older; or over 55 (and not working when first entitled)
returns to work performing non-comparable SGA, for definition of comparable SGA see DI 10515.015
entitled to TWP. After TWP, suspend benefits. Benefits remain in suspense (S9/MISCEL.), and do not terminate. Medicare continues.
NOTE: The statute provides that these individuals continue to meet the definition of disability, even though benefits are not payable, and does not cease (therefore a grace period is not applicable). Consequently, the normal EPE rules do not apply.
returns to work performing comparable SGA
entitled to TWP and EPE. Benefits terminate (T8) after EPE. Medicare terminates subject to extended Medicare rules. Period of disability (freeze) continues.
becomes entitled to benefits at or after age 55 while performing non-comparable SGA.
not eligible for TWP. Benefits remain in suspense (S7) and do not terminate. Becomes eligible for Medicare after 24 months.
starts performing comparable SGA
entitled to TWP and EPE. Benefits terminate (T8) after EPE. Medicare terminates subject to extended Medicare rules. Period of disability (freeze) continues.
the last previous work ended because of an impairment, and the current work requires a significant vocational adjustment
entitled to TWP and EPE. Benefits remain in suspense (S7), and do not terminate. Medicare continues.
NOTE: Beneficiaries in freeze status who have already completed a TWP and become re-entitled through the DIB attainment process are not eligible for another TWP, regardless of whether work is comparable, or non-comparable work.
G. Policy for statutory blindness not previously established
During a work CDR, a beneficiary may allege or have evidence of a visual impairment that we have not previously documented. This information may surface through responses on the SSA-821-BK, or SSA-820-BK through observations, or the beneficiary’s protest after receiving the work CDR due process notice. Develop the issue of blindness if:
* The beneficiary receives Supplemental Security Income; or
* The beneficiary’s work activity is above the non-blind SGA guidelines.
Beneficiaries participating in the Ticket to Work program with a Ticket in use are also entitled to receive a statutory blindness determination if they allege or have evidence of a visual impairment. The determination is an initial determination for statutory blindness only. Do not initiate a full medical CDR. Follow the field office (FO) procedures provided in DI 13010.135G.1. in this section and the disability determination services (DDS) procedures provided in DI 13010.135G.2.; the DDS must make a statutory blindness only determination, and not a determination of continuing disability.
1. FO procedures for processing work CDRs for beneficiaries with allegations or evidence of visual impairment
If the beneficiary alleges or has evidence of a visual impairment during the work CDR, and meets the requirements in DI 13010.135G, the FO should take the following actions:
* Obtain an SSA-820-BK or SSA-821-BK, SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA) and SSA-795 (Statement of Claimant or Other Person). The SSA-795 must include:
* The visual impairment alleged onset date;
* The name, address, telephone number, and fax number of each medical source related to the visual impairment only;
* The date first seen by each medical source for his or her visual impairment; and
* The following language: “A determination as to statutory blindness only is required – other impairments are not now a consideration.”
* Do not make an SGA determination on the work CDR.
* Ask about the beneficiary’s preferred method of communication with SSA (for special notice option (SNO) compliant).
* File the required forms in a brown folder, as this is an Electronic Disability Collection System (EDCS) exclusion case per DI 81010.030. Do not associate a prior folder with this claim.
* Complete and attach the paper flag (to require a statutory blindness determination) to the front of the brown folder. A copy of the paper flag appears in the attached exhibit in DI 13010.135J.
* Send the folder to DDS and use eWork to control for return of the case from the DDS (add the Stat Blind determination issue on the eWork Development worksheet). Annotate the Disability Control File (DCF) Remarks screen with information indicating a statutory blindness determination is pending.
NOTE: Check the MBR for a possible special message indicating the beneficiary previously alleged blindness or a visual impairment, or a blindness determination previously made, and document the information on the flag to alert the DDS. Also, be aware of SSI eligibility. The Title XVI record may require a blind determination.
2. DDS procedures when determining statutory blindness
Once the DDS receives the folder they will only develop and make a determination for statutory blindness. The DDS receipts the claim as a continuing disability review (CDR) using Continuing Disability Review Type CDT code “13” (Miscellaneous) For Exhibit of DDS Receipt (DREC) data input screen see SM 06001.115 and for CDT Codes see SM 06001.120.
NOTE: It is not necessary to retrieve the original folder.
Once the DDS completes the statutory blindness determination, follow the guidelines outlined in section a. or b. of this subsection:
* For determinations that find the beneficiary statutorily blind:
* Document the determination on Form SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal - Title II). For instructions on how to complete the SSA-833, see DI 13010.135I.
* Prepare a personalized disability explanation (PDE) attachment that explains the unfavorable onset date, if the established onset date of statutory blindness is not fully favorable. Return the PDE to the FO.
* Add a message to the certified electronic folder (CEF) documenting the Stat Blind determination.
* For determinations that find the beneficiary not statutorily blind:
* Document the determination on Form SSA-833. For instructions on how to complete the SSA-833, see DI 13010.135I.
* Prepare a PDE attachment that explains the statutory blindness determination and return the PDE attachment to the FO. The FO will include the PDE in the due process notice.
* Add the following language as the introductory paragraph: We evaluated your visual disorder to determine if you meet special earnings requirements due to blindness. After carefully reviewing all of the information, we find that you do not meet our blindness requirements.
For information on Personalized Disability Explanation Requirement General see DI 26530.010.
* Send the completed SSA-833 and the PDE in the brown folder with the statutory blindness coversheet flag to the FO.
H. FO procedures when DDS completes a determination for statutory blindness.
The FO will process the determination for statutory blindness, and release the due process notice with the PDE; once received from the DDS.
NOTE: The appeals level process does not change for this situation. Follow normal appeals procedures. The unfavorable blind determination is an initial blind determination in a post entitlement situation.
1. Statutory blindness found
For determinations that find the beneficiary statutorily blind:
* Add a special message to the MBR: Statutory Blindness established as of (list blind onset date);
* Contact the PC of jurisdiction to update the MBR reflecting the beneficiary was approved for statutory blindness, for FO or PC Telephone Numbers/Paperless Fax Numbers see GN 01070.209;
* Delete the pending work CDR in eWork, and re-establish a new eWork work review:
* On the Establish Work Review screen, check the STAT BLIND box.
* Process the eWork determination using the statutory blindness SGA rules.
* Place a copy of the SSA-833 and the DDS PDE blind decision in eView or the NDRed, as appropriate.
2. Statutorily blindness not found
For determinations that find the beneficiary not statutorily blind:
* Process the work CDR in eWork using non-blind SGA guidelines;
* Include the DDS PDE that explains the statutory blindness determination with the due process notice;
* Hold the paper folder for 65 days for possible appeal of the statutorily blind determination, after finalizing the decision; and
* Place a copy of the SSA-833 with the statutory blindness decision and the PDE in eView or NDRED, as appropriate.
I. Completion of Form SSA-833
1. Statutory blindness established
Complete the following items when establishing statutory blindness:
* Items 1–8 – Complete in the normal manner per DI 28084.000.
* Item 10 – Check block D “OTHER.”
* Item 12 – Enter code 30 and medical listing number 2.02 or 2.03A.
* Item 20 – Enter code 21 “Other.”
* Item 21 – Enter “Statutory Blindness,” body system code 02, and diagnosis code 3694.
* Item 23A-C – Enter diary information per DI 26525.000.
* Item 24 – Enter remark “Statutory blindness only determination. Onset of statutory blindness established (MMDDYY)."
* Items 25-28 and Items 30-33 – Complete these items in the normal manner per DI 28084.000.
2. Statutory blindness not established
Complete the following items when the reviewer does not establish statutory blindness:
* Items 1-8 – Complete in the normal manner per DI 28084.000.
* Item 10 – Check block D “OTHER.”
* Item 20 – Enter code 21 “Other.”
* Item 24 – Enter remark “Statutory blindness only determination. Statutory blindness not established.”
* Items 25-28 and Items 30-33 – Complete these items in the normal manner per DI 28084.000.
J. Exhibit of the FO and DDS Statutory Blindness Coversheet Flag as listed
The FO and DDS will complete this cover sheet when the statutorily blindness determination has been completed.
View PDF Version
K. DIB attainment
Statutory blind individuals may be entitled to a disability freeze even if they are performing SGA. For policy on Title II Disability Freeze instructions see DI 26001.010. The period of disability does not end for statutorily blind beneficiaries when their cash benefits terminate due to work activity. These individuals remain in a disability freeze.
When a statutorily blind individual in disability freeze status stops performing SGA, he or she must file a new application to have benefits started again through the DIB attainment process. OCO/PSC has responsibility for DIB attainment cases. For DIB attainment procedures see DI 41005.010.
NOTE: Title II statutory blind freeze does not apply to claims filed under DWB and CDB, for Eligibility for Disability Insurance Benefits (DIB) or the Disability “Freeze” see DI 10105.005.
L. Expedited Reinstatement (EXR) for the statutory blind
The requirements for EXR apply to statutory blindness in the same manner they apply to disability based on other impairments. If a statutorily blind individual chooses to file for EXR, do not use the DIB attainment process normally used to re-entitle a statutorily blind individual to cash benefits in Title II. For more information on EXR for statutorily blind individuals, see DI 13050.001D.
NOTE: Apply EXR for Over Age 55 Blind beneficiaries only if the TWP completed and benefits terminated based on SGA. For Policy Disability Based on Statutory Blindness over Age 55 blind beneficiaries, see DI 13050.001D.3.
M. References
DI 10515.010 Processing Claims of Blind Persons Involving Work in 1978 or Later
DI 26005.005 Title XVI Statutory Blindness Evaluation Issues
DI 28084.010 Adjudicative Level, Determination Findings, and Basis for Determination (Items 8 to 10)
DI 55025.001 Determining Ticket Status
DI 81010.030 Certified Electronic Folder (CEF) Exclusions and Limitations

POMS Reference

DI 13010.135: Title II Continuing Disability Considerations in Blindness Cases