DI 13050.001: Expedited Reinstatement (EXR) Overview

changes
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~~Effective Dates: 02/28/2018 - Present~~
Effective Dates: 06/06/2018 - Present
TN 6 (02-18)
DI 13050.001 Expedited Reinstatement (EXR) Overview
A. Introduction to EXR
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.
NOTE: 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 of February 1996 or later.
B. Policy for Title II and Title XVI EXR eligibility
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.
1. Requirements for EXR eligibility
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).
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.
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.
~~NOTE: Claimants whose prior entitlement is a closed period of disability are not eligible for EXR.~~
NOTE: Closed periods do not apply to EXR entitlement and claimants whose prior entitlement is a closed period of disability are not eligible for EXR.
2. Initial Reinstatement Period (IRP)
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.
C. Title II EXR policy
1. EXR requirements
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.
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.
2. Claimant with prior EXR technical denial
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.
3. Claimant entitled to another disability benefit
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.
4. Claimant entitled to reduced retirement insurance benefits (RIB)
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.
NOTE: For retirement benefit computation purposes, consider the period of disability and the EXR period to be one period of DIB.
5. Auxiliary reinstatement
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.
D. Title XVI EXR policy
1. EXR requirements
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.
2. Claimant with prior EXR technical denial
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.
3. Eligible spouse
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.
4. EXR request after prior EXR approval
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.
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.
E. EXR policy for disability based on statutory blindness
1. EXR requirements
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).
2. Medical review
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.
3. Statutory blind beneficiaries over age 55
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.
F. Overview of component responsibilities
1. FO responsibilities
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).

POMS Reference

DI 13050.001: Expedited Reinstatement (EXR) Overview