TN 2 (01-07)

Citations:

20 CFR Sections 404.1518; 404.1579(e)(2) and 404.1579(e)(3); 404.1579(g)(5) and 404.1579(g)(6); 404.1587; 404.1594(e)(2) and 404.1594(e)(3); 404.1594(g)(6) and 404.1594(g)(7); 404.1596(b)(2)(i); 404.1596(d) and 404.1596(e); 416.992; 416.994(b)(4)(ii) and 416.994(b)(4)(iii); 416.994(b)(6)(i); 416.994a(f)(2) and 416.994a(f)(3); 416.994a(g)(6)

A. Introduction

An FTC or WU issue may arise at any time during the continuing disability review (CDR) when a disabled individual cannot be located, does not furnish medical or other evidence, or fails to attend a scheduled physical or mental consultative examination by a certain date.

B. Policy

1. General

When SSA conducts a CDR, or there is a question about whether an individual continues to be disabled, the individual has a responsibility to provide medical or other evidence. In claims for title XVI disabled children; this responsibility ultimately rests with the applicant (usually the child's parent or other caregiver).

An individual's FTC, without good cause, and/or unknown whereabouts are reasons to cease or suspend benefits only when there is not enough evidence to justify a continuance.

2. Beneficiary fails to cooperate with the FO

A streamlined FTC process was implemented in the FO for medical CDRs on January 27, 2007. If the FO annotates the FTC decision to the DCF on or after January 27, 2007, the streamlined FTC process applies.

If the beneficiary fails to comply with the FO request for necessary information or evidence needed during a medical CDR, benefits will be suspended. If the FO’s DCF input to place the beneficiary in suspense fails, the PC must take manual action (using MACADE) to suspend title II benefits (See SM 03005.110). If the beneficiary does not cooperate during the period of suspension (12 months), benefits will be terminated automatically effective the 13^th month.

See DI 13015.005A. for additional information. The DDS will not make a medical determination.

3. Medical Improvement Review Standard (MIRS) and exceptions

The MIRS states that an individual's period of disability is continued unless his/her prior impairment(s) has improved since the last favorable disability determination, and the person can now engage in substantial gainful activity (SGA), where relevant, unless an exception applies.

The law provides for exceptions to medical improvement (MI) when disability can be found to have ended even though MI has not occurred.

(Citation: 20 CFR 404.1594(d) and (e), 416.994(b)(3) and (4))

Among the exceptions to the requirement for MI under the MIRS are the following:

Unless there is enough evidence to justify a continuance, SSA may find that an individual's disability has ended when there is a question whether the individual continues to be disabled and:

1. (FTC) the individual fails, without good cause, to go for a physical or mental examination or to furnish requested medical or other evidence necessary to determine if disability continues, or

2. (WU) SSA is unable to find the individual to determine if disability continues.

4. Cessation month

When there is not enough evidence to justify a continuance, in FTC cases (both titles II and XVI) and in WU cases, disability ceases in the first month in which:

1. (FTC) the individual fails, without good cause, to do what SSA/DDS has requested and the individual was aware that he/she had to cooperate and the repercussions of failing to do so. The DDS will make a medical decision that the disability ceased. See DI 13015.005 and DI 40525.001C. if the beneficiary fails to cooperate with the FO. In these situations, the DDS will not make a medical determination. See DI 28075.005F.2. for cessation month – FTC examples.

2. (WU) SSA/DDS learns that the individual's whereabouts are unknown, but no earlier than the month in which the continuing disability issue arose. This is a non-medical (title II) termination or a technical (title XVI) suspension of benefits, which is determined by the field office (FO).

5. Good cause

In determining whether an individual has good cause for failing to cooperate, consider the individual's limitations, i.e., physical, mental, educational and verbal (including any lack of facility with the English language). See GN 03101.020 for general guidelines regarding good cause determinations.

C. Procedure - general

1. Development

If the FTC or WU issue arises during the course of PC development, and development cannot be completed, document the file according to DI 13015.005A., (FTC), and DI 13015.005B.,(WU), and proceed as follows:

• Send the folder to the FO via a Form SSA-5526-U3 (Request for Assistance – Disability).

• Request FO assistance in locating the individual or in obtaining the individual's cooperation.

2. Individual does not cooperate

If the FO has taken all necessary actions, including the DCF input to place the beneficiary in suspense, but the DCF input failed to effectuate the suspension, the PC must take manual action (using MACADE) to suspend benefits (See SM 03005.110). The suspension will be effective the first month that does not cause an overpayment.

3. Individual is located or cooperates

1. If the individual is located and cooperates, process the CDR in the usual manner.

2. If the individual fails to comply with the FO request for necessary information or evidence needed to complete the CDR and is placed in suspense and then complies, prior to benefit termination, the FO will transfer the case to the DDS. This transfer action on the DCF will set an action item on the DCF, which will, trigger an MBR update record to resume benefits. If the DCF resumption action fails, the exception alert will be generated to the PC of jurisdiction. The PC should initiate manual reinstatement via MACADE to resume benefits (See SM 03005.110). Retroactive benefits are paid to the beneficiary and auxiliaries starting with the first month of suspension, if all other factors of entitlement are met.

3. If the beneficiary/payee provides the requested information for the CDR, but the case cannot be transferred to the DDS (e.g. there is an administrative delay on forwarding CDRs to the DDS(s)), benefits need to be reinstated if the beneficiary is otherwise eligible for title II benefits. The FO will contact the PC. The PC should initiate manual reinstatement via MACADE (See SM 03005.110).

4. Individual’s whereabouts are still unknown

If the beneficiary’s whereabouts are still unknown, the FO accepts jurisdiction and prepares the determination (See DI 13015.005B.).

5. Folder/Material received

If material is received from a FO which did not have the folder, forward to the servicing FO for their action.

D. Procedure- Title II benefits terminated due to failure to cooperate, family maximum payable

If title II benefits are terminated due to the disabled auxiliary’s (BIC = C or W) failure to cooperate and other auxiliaries are entitled on the record, redistribute the disabled auxiliary’s benefits to the other auxiliaries based on the family maximum provisions. The redistribution of the terminated disabled auxiliary’s benefits will be from the suspense start date to the time of termination.

E. Procedure - WU

If the FO has exhausted all efforts to locate the individual and the individual’s whereabouts are still unknown, proceed as follows.

1. FO had folder

a. Work issue

Process any work issue determination as usual. If the FO determined that an SGA cessation was not in order, assure that a WU cessation was processed and that due process was afforded prior to cessation of disability benefits.

b. Medical issue

Terminate benefits and prepare final cessation notice.

c. Work and medical issue

If the FO has not taken all the necessary action, see DI 40525.001E.2.

2. FO did not have folder

a. Medical issue only

• Afford due process (See DI 40525.095, Exhibit 1). Send to last known address.

• Prepare Form SSA-833-U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal—Title II) cessation determination based on WU.

b. Work issue only or work and medical issue — Title II

Make a work issue determination whenever possible using any available evidence of earnings. Use all methods and sources of wage verification outlined in DI 10505.005C. through DI 10505.005F. If there is sufficient evidence in file prior to identification of the WU issue to cease benefits, prepare a SSA-833-U3 determination with the month of cessation as indicated by the work activity. NOTE: If a cessation is prepared, send due process to last known address.

If available information is inconclusive, document that evidence is insufficient to make SGA determination, send due process to the last known address (See DI 40525.095, Exhibit 1) and prepare a SSA-833-U3 cessation based on WU.

F. References

• FO FTC and WU procedures, DI 13015.001 through DI 13015.025

• DDS FTC and WU procedures, DI 28075.005