DI 13050.001:
Expedited Reinstatement (EXR) Overview
Effective Dates: 03/10/2011 - Present- Effective Dates: 02/02/2018 - Present
TN 2 (02-06)- TN 6 (02-18)
DI 13050.001 Expedited Reinstatement - Overview- DI 13050.001 Expedited Reinstatement (EXR) Overview
A. Introduction- A. Introduction to EXR
Public Law 106-170, the Ticket to Work and Work Incentives Improvement Act of 1999 added sections 223(i) and 1631 (p) to the Act to allow certain previously entitled individuals to request expedited reinstatement (EXR) of those disability benefits or payments under title II and Title XVI when their medical condition no longer permits them to perform substantial gainful activity (SGA) within 60 months of their prior termination. EXR is thus a safety net for those individuals who make use of SSA-administered work incentives, successfully return to work, and, consequently, lose their entitlement to, or eligibility for, Title II or Title XVI benefits and payments.- The Ticket to Work and Work Incentives Improvement Act of 1999 added sections 223(i) and 1631(p) to the Social Security Act (Act) to allow previously entitled beneficiaries, whose entitlement ended due to work, to request EXR of those disability benefits or payments under Title II and Title XVI. A previously entitled beneficiary may become eligible for EXR if their medical condition no longer permits them to perform substantial gainful activity (SGA) within 60 months of their prior termination. EXR establishes a new period of disability with a new month of entitlement. EXR allows a claimant to receive up to 6 months of provisional cash benefits while the Social Security Administration (SSA) conducts a medical review to determine if the claimant qualifies for reinstatement to benefits. The claimant may also be eligible for Medicare or Medicaid coverage during the provisional benefit period.
To qualify for EXR, an individual must:* Not be performing SGA in the month he/she applies for EXR,* Be unable to work at the SGA level due to his or her medical condition,* Have stopped performing SGA within 60 months of his or her prior termination,* Have his/her current medical impairment(s) be the same as or related to the original impairment(s), and* Be under a disability based on application of the medical improvement review standards (MIRS).- NOTE: No EXR benefits are payable prior to January 2001 for Title II and February 2001 for Title XVI.
The EXR provision allows an individual to receive up to 6 months of provisional (temporary) cash benefits while SSA conducts a medical review to determine whether the individual can be reinstated to benefits. However the EXR PIA is computed as if the EPE termination never happened (see DI 13050.060B.3.) The individual may also be eligible for Medicare and/or Medicaid coverage during the provisional benefit period.- B. Policy for Title II and Title XVI EXR eligibility
Under Title XVI, the individual's eligible spouse also may be eligible for up to 6 months of provisional payments and Medicaid coverage during the provisional benefit period.- Effective April 17, 2017, new rules allow previously entitled beneficiaries to apply for EXR in the same month they stop performing SGA. Provisional benefits will begin the month after the request for EXR if the claimant stops performing SGA in the month of the request. For requests filed prior to April 17, 2017, field office (FO) technicians must deny the request for EXR if the claimant performed SGA in the month of the EXR request.
EXR establishes a new period of disability with a new onset date. An individual reinstated under EXR is given a 24-month initial reinstatement period (IRP) (see DI 13050.066). After completing the IRP, a Title II beneficiary is provided a new trial work period (TWP) and an extended period of eligibility (EPE). If benefits are ceased again after completing the EPE, a Title II beneficiary can be reinstated through a new request for EXR, if EXR eligibility criteria are met (see DI 13050.001B.). After completing the IRP, a Title XVI recipient whose benefits cease due to work can be reinstated through a new request for EXR, if EXR eligibility criteria are met (see DI 13050.001C.).- 1. Requirements for EXR eligibility
EXR is effective January 1, 2001. No EXR benefits are payable prior to January 2001 for Title II and February 2001 for Title XVI. The individual must have a previous entitlement or eligibility termination date (normally represented by the DBC date on the MBR or the T31 date on the SSR) of February 1996 or later. Closed periods are not applicable to EXR.- A previously entitled beneficiary, whose entitlement ended due to work, is eligible for EXR if they meet all of the following requirements:
- * is “not able” or “becomes unable” to work at the SGA level due to his or her medical condition,
- * is “not able” or “becomes unable” to perform SGA in the month of the EXR request,
- * stopped performing SGA within 60 months of his or her prior termination,
- * has a current medical impairment(s) that is the “same as or related” to the original impairment(s), and
- * is under a disability based on application of the medical improvement review standard (MIRS).
B. Policy - Who Can Be Reinstated - Title II- Claimants are “not able” to perform SGA if, in the month of their EXR request, they do not work or their work is not SGA.
1. Requirements- Claimants “become unable” to perform SGA if, in the month of their EXR request, their work is SGA, but they stop performing SGA by the day they file their request. To meet the requirement of having become unable to perform SGA, they must also not perform SGA in the month following the EXR request.
An individual who meets all of the following requirements is eligible for EXR:* previous entitlement to disability insurance benefits (DIB), disabled widow(er) benefits (DWB), or disabled child benefits (CDB) was terminated due to performance of SGA;* is not performing SGA in the month of the EXR request;* is unable to perform SGA because of his or her medical condition (see DI 13050.001G.);* the current disabling impairment(s) is the same as or related to the impairment(s) that was the basis for the previous disability entitlement (referred to as “same as or related”);* under a disability based on the application of the medical improvement review standards (MIRS); and* requests EXR within the consecutive 60-month period beginning with the month of entitlement termination. The EXR request period may be extended if the individual establishes good cause for late filing of the EXR request (see DI 13050.010A.2.).- NOTE: Claimants whose prior entitlement is a closed period of disability are not eligible for EXR.
NOTE: Even though no monthly cash benefits are paid, the expedited reinstatement provision is applicable to a Medicare Qualified Government Employee (MQGE) beneficiary.- 2. Initial Reinstatement Period (IRP)
2. Individual With Prior EXR Technical Denial- A beneficiary or recipient reinstated under EXR receives a 24-month initial reinstatement period (IRP). After completing the IRP, a Title II beneficiary gets a new trial work period (TWP) and an extended period of eligibility (EPE). If benefits terminate again after completing the EPE, we may reinstate a Title II claimant through a new request for EXR, if the claimant meets the EXR eligibility criteria. After completing the IRP, we can reinstate Title XVI claimants whose benefits stop due to work through a new request for EXR, if the claimant meets EXR eligibility criteria. For more information on the IRP, see DI 13050.066 and DI 13050.067.
If an individual was denied EXR because he or she did not meet the requirements for EXR (not filed within 60 months, etc.) the principles of res judicata may be applied to a subsequent EXR request. Res judicata cannot be applied if any aspect of the case has changed, including laws or regulations. See GN 03101.160B. for situations in which res judicata is applicable.- C. Title II EXR policy
3. Individual Entitled to Another Disability Benefit- 1. EXR requirements
If an individual requesting EXR is currently entitled to another disability benefit, the FO cannot apply collateral estoppel procedures. The DDS must make the medical determination that the impairment is the same as or related to the impairment that was the basis for the previous entitlement, and then make a determination that the individual is disabled based on the MIRS standard. Therefore, collateral estoppel procedures can not be applied.- Claimants previously entitled to disability insurance benefits (DIB), disabled widow(er) benefits (DWB), or childhood disability benefit (CDB) whose monthly benefits terminated due to SGA must meet the requirements listed in DI 13050.001B.1 in this section to be eligible for EXR.
4. Individual Entitled to Reduced RIB- NOTE: The EXR provision is applicable to a Medicare Qualified Government Employee (MQGE) beneficiary, which allows reinstatement to Medicare, even though we do not pay monthly benefits.
See RS 00615.110B.2. if the individual became entitled to reduced RIB simultaneously with or after the EXR month of entitlement. See RS 00615.110B.3. if the individual became entitled to reduced RIB before the EXR month of entitlement.- 2. Claimant with prior EXR technical denial
NOTE: For retirement benefit computation purposes, the period of disability reinstated by the EXR and the EXR period are considered one period of DIB.- If we deny a request for EXR for failure to meet the non-medical requirements for EXR (not filed within 60 months, etc.), we may apply the principles of res judicata to a subsequent request. Res judicata does not apply if any aspect of the case has changed, including laws or regulations. For situations in which res judicata is applicable, see GN 03101.160B.
5. Auxiliary Reinstatement- 3. Claimant entitled to another disability benefit
When a wage earner is approved for EXR, an auxiliary on the original record can file for reinstatement on the record. The auxiliary must file a new application for benefits and must meet current factors of entitlement (see DI 13050.060A.2.).- If a claimant requesting EXR is currently entitled to another disability benefit, the FO cannot apply collateral estoppel procedures to approve the EXR request. The disability determination services (DDS) must make the medical determination that the impairment is the same as or related to the impairment that was the basis for the previous entitlement, and then make a determination that the claimant is disabled based on the MIRS.
C. Policy - Who Can Be Reinstated – Title XVI- 4. Claimant entitled to reduced retirement insurance benefits (RIB)
1. Requirements- If the claimant became entitled to reduced RIB simultaneously with or after the EXR month of entitlement (MOE), see RS 00615.110B.2. If the claimant became entitled to reduced RIB before the EXR MOE, see RS 00615.110B.3.
An individual who meets all of the following requirements is eligible for EXR:* previous SSI disability/blindness eligibility was terminated because of excess earned income or a combination of earned and unearned income;* is not performing SGA in the month of the EXR request;* is unable to perform SGA due to his or her medical condition (see DI 13050.001G.);* the current disabling impairment(s) is the same as or related to the impairment(s) that was the basis for the previous disability entitlement;* under a disability based on the application of the medical improvement review standards (MIRS);* requests EXR within the consecutive 60-month period beginning with the month of termination of eligibility to SSI payments. The EXR request period may be extended if the individual establishes good cause for late filing of the EXR request (see DI 13050.010); and* meets all non-medical requirements for eligibility to SSI.- NOTE: For retirement benefit computation purposes, consider the period of disability and the EXR period to be one period of DIB.
2. Individual With Prior EXR Technical Denial- 5. Auxiliary reinstatement
If an individual was denied EXR because he or she did not meet the requirements for EXR (not filed within 60 months, etc.) the principles of res judicata may be applied to a subsequent EXR request. Res judicata cannot be applied if any aspect of the case has changed, including laws or regulations. See GN 03101.160B. for situations in which res judicata is applicable.- When we approve a number holder’s request for EXR, an auxiliary on the original record can file for reinstatement on the record. The auxiliary must file a new application for benefits and must continue to meet initial entitlement requirements, per DI 13050.060A.2.
3. Eligible Spouse- D. Title XVI EXR policy
An eligible spouse can also request to be reinstated.- 1. EXR requirements
4. EXR Request After Prior EXR Approval- A previously entitled recipient whose monthly benefits terminated due to excess earned income (or a combination of earned and unearned income) must meet all of the requirements listed under DI 13050.001B.1 in this section and meet all non-medical Title XVI requirements to be eligible for EXR.
An individual must complete the 24-month initial reinstatement period (IRP) to qualify for a subsequent period of EXR entitlement. If an individual has not completed the IRP, he or she does not qualify for a subsequent period of EXR.- 2. Claimant with prior EXR technical denial
EXAMPLE: Mr. Smith’s Title XVI benefits were reinstated through EXR as of 3/02. Mr. Smith returns to work as of 6/03 and has earnings over the threshold amount, making him ineligible for cash benefits and 1619(b). Mr. Smith continues to work and his Title XVI benefits terminate as of 6/04 after 12 months of payment ineligibility. Mr. Smith contacts SSA in 7/05 to state that he is no longer able to perform SGA and wants to apply for EXR. Since Mr. Smith only completed 15 months of his IRP (3/02 through 5/03) he can not be reinstated under EXR.- If we deny a request for EXR for failure to meet the non-medical requirements for EXR (not filed within 60 months, etc.), we may apply the principles of res judicata to a subsequent request. Res judicata does not apply if any aspect of the case has changed, including laws or regulations. For situations in which res judicata is applicable, see GN 03101.160B.
D. Policy - Disability Based On Statutory Blindness- 3. Eligible spouse
1. Requirements- An eligible spouse can also request reinstatement, and may be eligible for up to 6 months of provisional benefits and Medicaid coverage during the provisional benefit period.
The requirements for EXR apply to statutory blindness in the same manner they apply to disability based on other impairments (the individual's prior monthly benefits must have terminated due to SGA for Title II, or excess income/combination of earned and unearned income for Title XVI). A blind individual's work activity is evaluated under standards applicable to blind individuals in Title II (blind SGA standards) and Title XVI (blind work expenses, etc.).- 4. EXR request after prior EXR approval
2. Medical Review- A claimant must complete the 24-month IRP to qualify for a subsequent period of EXR entitlement. If a claimant has not completed the IRP, he or she does not qualify for a subsequent period of EXR.
To qualify for EXR, the statutorily blind individual must undergo the same medical review process as a non-blind individual. The individual must therefore undergo a same as or related determination and a MIRS review. The DIB attainment process normally used to re-entitle an individual to cash benefits in Title II is not used in EXR processing. See DI 28057.001D.- EXAMPLE: We reinstated Mr. Smith’s Title XVI benefits through EXR as of 3/14. Mr. Smith returns to work as of 6/15 and has earnings over the threshold amount, making him ineligible for cash benefits. Mr. Smith continues to work and his Title XVI benefits terminate as of 6/16 after 12 months of payment ineligibility. Mr. Smith contacts SSA in 7/17 to state that he is no longer able to perform SGA and wants to apply for EXR. Since Mr. Smith only completed 15 months of his IRP (3/14 through 5/15), he is not eligible for reinstatement under EXR.
3. Over Age 55 blind beneficiaries- E. EXR policy for disability based on statutory blindness
EXR is applicable for blind beneficiaries only if he or she completed the TWP and benefits were terminated based on SGA. If the beneficiary is currently in suspense status (see DI 10515.015B) he or she does not meet the requirements for EXR.- 1. EXR requirements
E. Procedure - Disability Based On Statutory Blindness- The requirements for EXR apply to statutory blindness in the same manner they apply to disabilities based on other impairments when the previous monthly benefits have terminated due to SGA for Title II or excess earned income (or a combination of earned and unearned income) for Title XVI. Evaluate a blind claimant's work activity under standards applicable to beneficiaries with statutory blindness in Title II (blind SGA standards) and Title XVI (blind work expenses).
If a medical decision is needed, the FO will take the EXR request and supplemental forms and forward them to the DDS. The DDS will make an EXR decision (and then a comparability decision, if necessary, for an over age 55 individual). If approved, the FO will process the award in the same manner as other EXR cases.- 2. Medical review
F. Policy - Proper Applicant- To qualify for EXR, the statutorily blind claimant must undergo the same medical review process as a non-blind disabled claimant. The claimant must therefore undergo the “same as or related” determination, and a MIRS review. The DDS will make an EXR decision and then a comparability decision, if necessary, for a claimant over age 55. If approved, the FO will process the award in the same manner as other EXR cases. Do not use the DIB attainment process normally used to re-entitle a claimant to cash benefits in Title II EXR processing. For more information on DIB attainment, see DI 13010.135 and DI 41005.010.
The claimant (or someone who has the right to sign a valid request on his or her behalf) must sign the EXR request. See GN 00204.003 for instructions on who can be considered a proper applicant. See GN 00502.100 through GN 00502.107 when representative payee development is needed.- 3. Statutory blind beneficiaries over age 55
EXR requests are currently excluded from the signature alternatives described in GN 00201.015, as they are MCS and MSSICS exclusions. The paper EXR request must be signed and retained in the claims folder.- EXR is applicable for blind claimants only if they completed the TWP and benefits terminated based on SGA. If the claimant is currently in suspense status, he or she does not meet the requirements for EXR, see DI 10515.015B.
If the individual dies after a protective writing has occurred, but before the EXR request is filed, follow the instructions in GN 00204.005. If the reinstatement request is for Title XVI benefits, see SI 02101.003 for instructions on who may receive a Title XVI underpayment.- F. Overview of component responsibilities
G. Policy – “Unable to Perform SGA” Determination- 1. FO responsibilities
We will determine that an individual is unable to perform SGA due to his/her medical condition when all of the following three conditions are met:* The individual certifies that he/she is unable to perform SGA because of his/her medical condition. This certification is obtained when the individual submits a signed SSA-371/372/373 (see Exhibits 1 through 3 in DI 13050.105);* The individual does not perform SGA in the month he/she requests EXR; and* The individual is found by the DDS to be under a disability based on the application of the Medical Improvement Review Standards (MIRS) (see DI 13050.005A.3.).- The FO is responsible for taking the following actions:
- * Discuss the criteria for reinstatement with the claimant, and provide a comparison of the possible effects of requesting EXR versus filing a new initial claim. For complete instructions on EXR versus a new claim, see DI 13050.020. For complete EXR interview instructions, see DI 13050.045 and DI 13050.050.
- * Assist the claimant with the request for reinstatement, obtain the prior folder, and determine whether the claimant meets the applicable non-medical criteria.
- * Initiate provisional benefits via the Post Entitlement Online System (POS) (if applicable) for Title II, or by establishing a start-date record for Title XVI. For complete provisional benefit instructions, see DI 13050.025 and DI 13050.030.
- * For Title II claims, the FO identifies all SGA and non-SGA months in the 12-month period prior to the month of filing or from the benefit termination month (BTM), whichever is later, on the SSA-823.
- * If the claimant meets all the non-medical requirements for EXR, the FO sends the case to the DDS for a medical decision and controls the case with the disability control file (DCF).
- * If the claimant does not meet the non-medical requirements for EXR, and the claimant insists on filing for EXR, the FO issues a technical denial. For technical denial instructions, see DI 13050.065.
- * If the DDS denies the EXR, the FO terminates provisional benefits and issues a denial notice through the Document Processing System (DPS).
- * If DDS allows the EXR,
- For Title II, the FO will prepare the Electronic Form 101 (EF101) and forward it to the program service center (PSC) for processing.
- For Title XVI, the FO will terminate the record, stopping provisional benefits, and then start-date a new EXR record. For complete EXR award instructions, see DI 13050.060 and DI 13050.061.
- EXR requests are Modernized Claims Systems (MCS) and Modernized Supplemental Security Income Claim System (MSSICS) exclusions, and excluded from the signature alternatives described in GN 00201.015. Retain the signed paper EXR request and supporting documentation in the claims folder. Further, EXR requests are Electronic Disability Collect System (EDCS) exclusions and technicians must process them using a paper file. Fax documentation to eView or Claims File Records Management System (CFRMS) prior to sending the folder to the DDS per DI 13050.045B.
- 2. DDS responsibilities
- The DDS reviews the medical evidence and determines if the claimant's current impairment is the “same as or related” to the impairment that led to the previous entitlement to benefits, using the comparison point decision (CPD). If a “same as or related impairment” exists, the DDS will determine whether the claimant is disabled based on the MIRS. The DDS determines the EXR month of entitlement in allowance decisions. The DDS prepares an SSA-832 Title XVI Cessation or Continuance of Disability Determination and Transmittal, or SSA-833 Title II Cessation or Continuance of Disability to document the determination and returns the file to the FO. For complete instructions on DDS EXR claims processing, see DI 28057.000.
- NOTE: The decision that an impairment is “the same as or related to” is a medical decision that can only be made by the DDS.
- 3. PSC responsibilities
- The PSCs process all EXR awards for Title II benefits through the District Office Final Authorization (DOFA) procedures. The PSC will:
- * terminate provisional benefits, if necessary, and adjust the benefits payable for provisional benefits paid, and
- * adjudicate Medicare entitlement as appropriate, and
- * prepare and send the appropriate award and overpayment notices. For PSC EXR procedures, see SM 00856.000 and DI 13050.095.
- NOTE: The DCF controls EXR requests from the time of the request through adjudication. It is important to initiate the EXR event on the DCF and show the transfer of the case between the FO, DDS and PSC to control the cases accurately, as well as to provide accurate management information. Further, controlling the EXR case through the DCF will help ensure the accuracy of future actions during the IRP, TWP and EPE (if applicable).
x
← This means that the line
was removed and
was added – in other words, the "Effective Dates" line at the top of the document has been updated to reflect that the new version is effective as of the date the change was made.