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DI 52150.055: Protected Increases and Breaks in Workers’ Compensation/Public Disability Benefit (WC/PDB) Payments, Offset and Entitlement

changes
← * →
  • Effective Dates: 12/12/2013 - Present
  • Effective Dates: 04/05/2018 - Present
  • BASIC (09-08)
  • DI 52150.055 Protected Increases and Breaks in Workers’ Compensation/Public Disability Benefit (WC/PDB) Payments, Offset and Entitlement
  • Citations:
  • Social Security Ruling SSR 79-20
  • A. WC/PDB and protected increases
  • All increases in Social Security benefits for months after the first possible month of offset are protected from offset. The first possible month of offset is the first month offset is imposed or considered, whichever is earlier.
  • Offset is considered when offset is possible for a month and is either imposed or not actually applied because a high average current earnings (ACE) postpones offset or expenses are credited for the full month.
  • Increases due to a triennial redetermination of the ACE are also protected. See DI 52150.080 - Triennial Redeterminations (Redet) of Average Current Earnings (ACE).
  • B. Protected increases and WC/PDB offset - changes in Disability Insurance Benefits (DIB) entitlement, DIB benefit amounts, or family composition
  • 1. Subsequently entitled auxiliary - protected increases and WC/PDB offset
  • If one or more auxiliaries are entitled on or before the first possible month of offset, and another auxiliary is subsequently entitled in a later month, the newly awarded auxiliary is entitled to share in any protected increases as if he or she was entitled in the first possible month of offset.
  • 2. Subsequent period of Social Security DIB (break in DIB entitlement) – WC/PDB offset
  • Protected increases in a prior period of DIB are not protected for a subsequent period of DIB. In such cases, compute offset for the new period of DIB as if it were an initial DIB claim; i.e., compute a new average current earnings (ACE) and total family benefits (TFB). This applies even if the new period of DIB begins the month after the prior period of DIB ends.
  • For expedited reinstatement (EXR) cases, see the “NOTE” in DI 52150.055C.2. in this section and DI 52160.001 - Expedited Reinstatements with WC/PDB.
  • 3. SSA benefit increase in or before the first possible month of WC/PDB offset
  • Benefit increases that result from a recalculation of the primary insurance amount (PIA), a recomputation of the PIA, or a combined family maximum (CFM) are protected only if the increase is effective at least one month after the first possible month of offset. If the increase is effective retroactive to the first possible month of offset or earlier, recompute offset from the first possible month of offset.
  • 4. Combined Family Maximum (CFM) and WC/PDB offset
  • a. CFM applies in or before first possible month of offset
  • If a CFM applies in or before the first possible month of offset, use the auxiliary rates computed from the CFM to determine the total family benefit (TFB).
  • b. CFM applies after first possible month of offset
  • If a CFM becomes applicable in a month after the first possible month of offset, benefit increases that result from the CFM are protected during the period the CFM applies.
  • The Interactive Computation Facility (ICF) cannot accurately compute offset if a CFM exists. Manual computations are necessary using the following forms:
  • * SSA-2455 “Offset Worksheet – Disability Insurance Benefits” (see DI 52170.010) - use when there is no change in the WC/PDB rate after a triennial redetermination of the ACE applies;
  • * SSA-2454 “Offset Worksheet – Triennial Redetermination Previously Applied” (see DI 52170.020) - use if, during the period the CFM applies, a triennial redetermination of the ACE applies and there is a subsequent change in the WC/PDB rate.
  • NOTE: Complete an ICF function 34 (OREO) Datasheet to show the results of the manual computations.
  • c. CFM terminates
  • To determine the amounts payable after offset, effective the CFM termination month, recompute offset from the first possible month of offset up to and including the CFM termination month for the remaining auxiliaries (as if the CFM never existed).
  • NOTE: If there is a decrease in the DIB monthly benefit amount (i.e., a decrease in the MBA due to the January 1981 CFM limit), the benefits after offset decrease accordingly.
  • C. Break in WC/PDB entitlement, payment, or offset - no break in DIB entitlement
  • 1. Break in WC/PDB entitlement
  • A break in WC/PDB entitlement means the wage earner is not entitled to receive WC or PDB for a period of at least one month and, therefore, we must remove offset for the period of non-entitlement to WC or PDB.
  • Example:
  • * A number holder (NH) has an industrial accident on 08/13/2006 that results in temporary total (TT) disability payments.
  • * TT stops 07/23/2007 because the NH medically improves and returns to work on 07/24/2007. WC entitlement (based on the 08/03/2006 injury) ceases.
  • * The NH suffers another on-the-job injury on 09/01/2007 and receives a new and separate WC award based on the new injury.
  • * A new Offset First Considered date is established and offset is imposed again based on the new WC entitlement/award.
  • 2. Break in WC/PDB offset with no break in WC/PDB entitlement
  • A break in WC/PDB offset (e.g., beneficiaries may be in and out of offset) can occur even when the number holder’s entitlement to WC/PDB is continuous. The following situations can result in a break in WC/PDB offset, but WC/PDB entitlement is continuous:
  • * A break in WC/PDB payment occurs, and all payments are based on the same injury or illness (e.g., an interruption in WC/PDB payment pending a permanent disability rating, not because of a new and separate WC/PDB award). See DI 52150.055C.3. in this section.
  • * The WC/PDB rate changes to a lower amount.
  • * Excludable expenses preclude offset for at least one month.
  • * A high ACE applies at least one month after the first possible month of offset.
  • * Reverse offset applies at least one month after the DIB MOET and offset is later reimposed (for example, certain States' reverse offset ends at age 62 and DIB is then subject to offset at age 62 attainment). For breaks in WC/PDB offset due to reverse offset, see DI 52105.001.
  • EXAMPLE: The NH’s temporary WC payments stop pending a permanent disability rating for that injury/illness, (i.e., additional payments are contemplated). Offset is removed. WC payments later resume at a lower permanent rate that does not cause offset. The WC permanent rate increases and offset is re-imposed.
  • NOTE: T8 months constitute a break in offset except in expedited reinstatement (EXR) cases when, in rare instances, the T8 month equals the month of entitlement (MOET) of the EXR. As an example, the first DIB line on the MBR is a T8 benefit termination month (BTM) of 11/2004 (first month benefits are not payable for this period of disability), the second DIB line (for the EXR period) shows a disability award code (DAC) of “F”, and benefits are payable 11/2004 (EXR MOET of 11/2004).
  • 3. Break (interruption) in WC/PDB payments – one WC/PDB injury/illness claim
  • A break in WC/PDB payment can occur when WC/PDB payments are based on one injury/illness claim. A break in WC/PDB payment results in a break in offset.
  • Example - break (interruption) in WC payments:
  • * The number holder (NH) has an industrial accident in 2007, which results in temporary total (TT) disability payments.
  • * The NH had a pre-existing medical condition not involving a work-related injury or illness.
  • * TT stops November 23, 2008 because the carrier alleges any ongoing disability is not the result of the industrial accident. We remove offset.
  • * The NH appeals the WC decision and WC payments begin again, effective with the date of the decision.
  • * Offset is re-imposed effective with the date WC payments begin again.
  • * There is an interruption in WC benefits for the same injury. The Offset First Considered date remains the same.
  • NOTE: Determining whether an interruption of WC/PDB payments is due to a break in WC/PDB entitlement or whether additional payments are contemplated depends upon the laws, regulations, policies, and procedures of individual States, and they vary from State to State (For State-specific WC procedures, see DI 52120.001 and for State-specific PDB procedures, see DI 52135.001). If WC/PDB entitlement is continuous, even though WC/PDB payments are stopped and resumed, increases are protected.
  • D. Chart - Protected SSA benefit increases when there are breaks in WC/PDB entitlement, offset, or payment
  • Situation
  • Condition
  • Increase
  • New and separate WC/PDB award after WC/PDB payments for prior injury end (i.e., break in WC/PDB entitlement)
  • Corresponding break in offset
  • Not protected if due before the new WC/PDB entitlement date.
  • Break in offset with no break in WC/PDB entitlement or payment. This can occur when:
  • * The WC/PDB rate decreases so that a high ACE postpones offset for one or more months;
  • * Excludable expenses postpone offset for one or more months; or
  • * The TFB decreases.
  • (For breaks in offset due to reverse jurisdiction, see DI 52105.001.)
  • Offset is later re-imposed
  • Protected if effective for period of no offset
  • Break (interruption) in WC/PDB payments for the same injury/illness claim. (See DI 52150.055C.3. for definition, example and NOTE.)
  • Corresponding break in offset
  • Protected if resumed WC/PDB payments are based on same injury/illness. (For Notice Provision cases, see Social Security Ruling 79-20 .)
  • E. Examples
  • The following examples explain how SSA benefit increases affect rates payable after offset in various situations. In most cases, the ICF process computes offset (i.e., a manual computation is not necessary).
  • 1. Fourth auxiliary entitled - WC/PDB offset and protected increases
  • 12/2006 – DIB MOET and First Month of Offset –HA, HB2, HC2, HC1 entitled
  • Family Max
  • $1373.80
  • HA PIA
  • $915.90
  • HB2, HC2, HC1 MBA
  • $ 152.63 each (rounded down to $152.60)
  • TFB
  • $1373.70
  • 80% ACE
  • $1154.00
  • WC
  • $ 399.00 (monthly)
  • Because the TFB is higher than the 80%ACE, use the TFB amount to calculate offset (i.e., the TFB is the controlling factor when computing offset).
  • $1373.70 TFB
  •  
  • - 399.00 Monthly WC
  •  
  • $ 974.70 Payable to the family after offset
  •  
  • -$915.90 HA's MBA (PIA).
  • This amount is less than the amount payable to the family after offset. Therefore HA is not offset and his full MBA is payable.
  •  
  • $ 58.80 remainder (payable to the auxiliaries). Divide by 3 auxiliaries = $19.60 payable to each auxiliary after offset.
  •  
  • COLA 12/2007:
  •  
  • 12/2007 - HA PIA $936.90 (HA – no offset)
  • $21.00 increase
  • 12/2007 - HB2, HC2, HC1 MBA $156.13 (rounded down to $156.10 each)
  • $3.50 MBA increase for each auxiliary
  • Because HA's MBA is not offset, he receives the full increase and his rate payable effective 12/2007 is $936.90. Each auxiliary receives $23.10 in 12/2007 after offset ($19.60 12/2006 + $3.50 12/2007 increase).
  • In 01/2008, HC3 becomes entitled and shares in the protected increase. To calculate the rate payable after offset in 01/2008:
  • Go back to the first possible month of offset (12/2006)
  • and recalculate the offset amount as though HC3 were entitled
  • 12/2006
  • HA PIA
  • $ 915.90
  •  
  • 12/2006
  • HB2, HC3, HC2, HC1 MBA
  • $114.475 each (rounded down to $114.40 each)
  •  
  •  TFB
  • $1373.50
  •  
  •  WC
  • -399.00 (monthly)
  •  
  •  
  • $ 974.50 payable to family after offset
  •  
  •  
  • -915.90 HA’s MBA is less than the amount payable to the family after offset. Therefore HA is not offset.
  •  
  •  
  • $ 58.60 remainder (payable to the auxiliaries). Divide by 4 auxiliaries = $14.65 (rounded down to $14.60) payable to each auxiliary after offset.
  •  
  •  
  • 12/2007 COLA:
  •  
  • 12/2007
  • HA PIA
  • $936.90 (HA is not offset – due full PIA)
  • $21.00 PIA increase
  • 12/2070
  • HB2, HC3, HC2, HC1 MBA
  • $117.10 - MBA for each auxiliary
  • $2.70 MBA increase due each auxiliary
  •  
  • $14.60 payable after offset for 12/2006 for each auxiliary
  •  
  •  
  • + 2.70 12/2007 COLA (protected increase)
  •  
  •  
  •  
  •  
  •  
  • 01/2008 - HC’3’s Actual Month of Entitlement:
  •  
  • 01/2008 (four aux. entitled)
  • $17.30 - amount payable after offset effective 01/2008 for each auxiliary
  •  
  • HA is still not offset. Each of the four auxiliaries receives $17.30 after offset effective 01/2008 ($14.60 12/2006 + $2.70 12/2007 protected increase for four auxiliaries).
  • NOTE: If the ACE was the applicable limit in computing offset (rather than the TFB), the expedient in DI 52150.070C. can be used.
  • 2. Unreduced HB entitlement – WC/PDB offset and protected increases
  • Situation (HB rate limited by DMAX):
  • 02/2003
  • HA month of entitlement (MOET) (HA in Partial WC Offset) – PIA $657.00
  • 12/2007
  • HB MOET (full retirement age, or “FRA” - Unreduced for age)
  • Compute the spouse's protected increases as though she were entitled in the first month of offset (02/2003). Assume total offset for the HB in 02/2003 (because HA is in partial offset effective 02/2003). Her benefit payable after offset in 12/2007 (her MOET) is $25.10, the amount of the protected increases from the first possible month of offset (02/2003) through her HB MOET (12/2007). (Assume the January 2006 triennial redetermination of the ACE did not yield an increase.)
  • Determine the amount payable to HB effective 12/2007 by calculating the protected increases as follows:
  • Date & DMAX
  • HA PIA
  • HB MBA
  • HB MBA INCREASES
  • 02/2003 – $820.50
  • $657.00
  • $163.50
  • $ 0.00
  • 12/2003 – 837.70
  • 670.70
  • 167.00
  • 3.50
  • 12/2004 – 860.30
  • 688.80
  • 171.50
  • 4.50
  • 12/2005 – 895.50
  • 717.00
  • 178.50
  • 7.00
  • 12/2006 – 925.00
  • 740.60
  • 184.40
  • 5.90
  • 12/2007 – 946.20
  • 757.60
  • 188.60
  • 4.20
  • Total
  •  
  •  
  • $25.10 payable to HB effective 12/2007 (her MOET – also her FRA)
  • 3. HB entitlement – reduced for age - WC/PDB offset and protected increases
  • When computing the protected increases for a spouse entitled to a benefit reduced for age, use the same reduction factor (RF) for the first possible month of offset as the RF applicable for the spouse’s actual month of entitlement.
  • In Example #2 above, if HB is entitled in 12/2007 with a RF of 24, use the same RF of 24 in determining her fictitious MBA effective 02/2003 (the first possible month of offset). MBAs retroactive to 02/2003 are needed to establish all protected increases from the first possible month of offset to her actual HB MOET (12/2007), thereby determining the HB amount payable after offset effective 12/2007.
  • 4. Dually entitled spouse - WC/PDB offset and protected increases
  • NOTE: The interactive computation facility (ICF) programs #31 and #32 cannot calculate offset for dual entitlement or technical entitlement situations. These computations must be done manually and input via OREO.
  • A spouse (HB) is entitled on her husband’s SSN effective 11/2003 (four years after her husband’s DIB MOET of 11/1999) and she is subject to WC offset on his account. She is also entitled to retirement benefits on her own SSN effective 11/2003:
  • 1999
  • Eligibility year (ELG)
  • 11/1999
  • HA DIB MOET
  • PIA $950.00
  • First possible month of offset
  • 11/1999
  • WC $375.00 (monthly)
  • ACE $1350.00 (higher than TFB – ACE controls offset)
  • 11/2003
  • HB MOET (DOB 10/15/1941)
  • 11/2003
  • 11/2003
  • HB entitled on her own RIB
  • RIB PIA $300.00
  • 12/2003
  • RIB PIA $306.30
  • 01/2004
  • RIB Recomputed PIA $314.00
  • In this dual entitlement example, HB/A benefits must be reduced for age. The reduction factor (RF) for her RIB and spouse's benefit is 43 based on her age and MOET.
  • When computing offset for HB, determine all protected benefit increases as though HB is entitled effective with the first possible month of offset (11/1999), and compute the “fictitious” MBAs for 11/1999-10/2003 (since HB isn’t really entitled until 11/2003) using the same RF (43). If HB was actually entitled in 1999, her ELY would be 1999. Therefore, the special 07/2001 COLA is included in her protected increases.
  • NOTE: ICF programs #31 and #32 cannot calculate a monthly benefit amount based on an RF of 43. To compute the reduced spouse’s rate effective 11/2003, use the WNPSC Tools Rate Computations at:
  • http://sfnet.sf.ssa.gov/western/rate_computations.htm
  • NOTE: ICF programs #31 and #32 cannot calculate a monthly benefit amount based on an RF of 43. To compute the reduced spouse’s rate effective 11/2003, use the WNPSC Tools Rate Computations - Click here.
  • You must de-convert the 11/2003 HB MBA (and her own RIB PIA) back to the first possible month of offset (11/1999). To determine HB’s protected increases for 12/2003 and 12/03, ICF de-converts the 11/2003 RIB PIA of $300.00 (based on an ELY of 1999) as follows:
  • EFF DATE
  • RIB PIA
  • 12/2002
  • 300.00
  • 12/2001
  • 295.90
  • 07/2001
  • 288.50
  • 12/2000
  • 288.20
  • 12/1999
  • 278.50
  • 11/1999
  • 272.00
  • The protected increases for 11/2003 and 12/2003 are calculated as follows:
  • Effective Date
  • DIB PIA
  • ½ DIB PIA
  • HB’s own RIB PIA
  • Full LEMBA
  • Reduced LEMBA- RF of 43
  • Protected Increases
  • 11/1999
  • 950.00
  • 475.00
  • 272.00
  • 203.00
  • 146.30
  • 0.00
  • 12/1999
  • 972.80
  • 486.40
  • 278.50
  • 207.90
  • 149.80
  • 3.50
  • 12/2000
  • 1006.80
  • 503.40
  • 288.20
  • 215.20
  • 155.10
  • 5.30
  • 07/2001
  • 1007.70
  • 503.80
  • 288.50
  • 215.30
  • 155.10
  • 0.00
  • 12/2001
  • 1033.90
  • 516.90
  • 295.90
  • 221.00
  • 159.30
  • 4.20
  • 12/2002
  • 1048.30
  • 524.10
  • 300.00
  • 224.10
  • 161.50
  • 2.20
  • Total protected increases as of 11/2003
  •  
  •  
  •  
  •  
  •  
  • 15.20
  • 12/2003
  • 1070.30
  • 535.10
  • 306.30
  • 228.80
  • 164.90
  • 3.40
  • Total protected increases as of 12/2003
  •  
  •  
  •  
  •  
  •  
  • 18.60
  • To figure her protected increases effective with the 01/2004 PIA Recomp, ICF deconverts the 01/2004 RIB PIA of $314.00 (based on an ELY of 1999) as follows:
  • EFF DATE
  • RIB PIA
  • 12/2002
  • 307.60
  • 12/2001
  • 303.40
  • 07/2001
  • 295.80
  • 12/2000
  • 295.40
  • 12/1999
  • 285.50
  • 11/1999
  • 278.90
  • The protected increases effective 01/2004 are calculated as follows:
  • Effective Date
  • DIB PIA
  • ½ DIB PIA
  • HB’s own RIB PIA
  • Full LEMBA
  • Reduced LEMBA- RF of 43
  • Protected Increases
  • 11/1999
  • 950.00
  • 475.00
  • 278.90
  • 196.10
  • 141.30
  • 0.00
  • 12/1999
  • 972.80
  • 486.40
  • 285.50
  • 200.90
  • 144.80
  • 3.50
  • 12/2000
  • 1006.80
  • 503.40
  • 295.40
  • 208.00
  • 149.90
  • 5.10
  • 07/2001
  • 1007.70
  • 503.80
  • 295.80
  • 208.00
  • 149.90
  • 0.00
  • 12/2001
  • 1033.90
  • 516.90
  • 303.40
  • 213.50
  • 153.80
  • 3.90
  • 12/2002
  • 1048.30
  • 524.10
  • 307.60
  • 216.50
  • 156.00
  • 2.20
  • 12/2003
  • 1070.30
  • 535.10
  • 314.00
  • 221.10
  • 159.30
  • 3.30
  • Total protected increases as of 01/2004
  •  
  •  
  •  
  •  
  •  
  • 18.00
  • * The WC monthly amount of $375.00 effective 11/1999 remains unchanged.
  • * Her husband is not offset:
  • ACE $1350.00 - $375.00 monthly WC = $975.00 payable after offset
  • $975.00 payable - DIB PIA $950.00 11/1999 = $25.00 remainder (payable to HB)
  • * Her total protected increases for 11/1999-11/2003 ($15.20) are added to the $25.00 remainder to compute the amount payable after offset for HB effective 11/2003 ($40.20), her date of entitlement to spouse’s benefits.
  • * The protected increase for 12/2003 ($3.40) is added to compute the amount payable after offset to HB effective 12/2003 ($ 43.60).
  • * The total protected increases for 11/1999-01/2004 ($18.00) are added to the $25.00 remainder to compute the amount payable after offset to HB effective 01/2004 ($ 43.00). (The 01/2004 recomputation increase in her own RIB PIA results in a lower amount payable after offset as a spouse (HB) effective 01/2004.)
  • 5. Complex Example - Parisi provision involved with WC and protected increases CFM
  • HA entitled 07/1999; PIA 885.20, FMAX = 1327.80D
  •  
  • No recomps apply in this case.
  •  
  • 100% ACE = 2388.00
  •  80% ACE = 1910.40
  •  
  • TFB will remain lower than 80% ACE for the entire entitlement period
  •  
  • WC Received = 340.57 Weekly (= 1475.80 per month)
  •  
  • HA will receive 434.60 after offset in 7/1999.
  • Protected increases are added in 12/1999, 12/2000, 07/2001, 12/2001;
  • MBA after offset in 12/01 is 512.80
  •  
  • Triennial redetermination in 01/2002 raised the 80% ACE to 2128.00; the redetermined HA rate was 652.20.
  •  
  • In 09/2002, HA's PIA is 963.40, and the table maximum is 1445.10D.
  • B2 and C1 become entitled. B2 is also entitled to her own HA, at a PIA of 465.30; a combined maximum of 1910.40 becomes effective.
  •  
  • The family rates are figured as if B2 and C1 were always entitled, but using the table maximum. The increase due to the combined maximum is treated as a protected increase:
  •  
  • To determine protected increases for B2 and C1 as of 01/02, we re-work the original 07/99 offset comp:
  • - HC1 benefit (adjusted for DMAX) = 221.30
  • - B2 is technically entitled, so that her LEMBA is effectively zero.
  •  
  •   80% ACE
  • = 1910.40
  •  
  • - monthly WC
  • = 1475.80
  •  
  •   Payable
  • =    434.60
  • — All goes to HA, none to C1.
  •  
  • Protected increases to C1 total 19.50 due to COLA increases through 12/01.
  •  
  • B2 is still technically entitled, so she gets no protected increases.
  •  
  • A's redetermined rate is 632.40, and C1 remains with the protected increases of 19.50.
  •  
  • The increase due to the CMAX is then treated as a protected increase:
  •  
  • - C1's benefit (before offset) adjusted for the CMAX:
  • 473.50
  • - C1's benefit (before offset) adjusted for the DMAX:
  • 240.80
  • - Protected increase due to CMAX:
  • 232.70
  • - Plus prior benefit after offset:
  •   19.50
  • - Total C1 payable after offset (before Parisi):
  • 252.20
  •  
  • - B2's LEMBA (before offset) adjusted for the CMAX:
  • 8.20
  • - B2's LEMBA (before offset) adjusted for the DMAX:
  •       0
  • - Protected increase due to CMAX:
  • 8.20
  • - Plus prior benefit after offset:
  •       0
  • - Total B2 payable after offset (before or after Parisi):
  • 8.20
  •  
  • We then deal with Parisi:
  • - Amount of CMAX not used because of B2's Dual Entitlement:
  • 465.30
  • - Amount to be made available to C1:
  •     - C1 adjusted benefit (before offset):
  •     - C1 original benefit:
  •  
  • 473.50
  • 481.70
  • - Amount to be added to C1 benefit after offset:
  • 8.20
  • - Previously computed C1 benefit after offset:
  • 252.20
  • - Total payable to C1 in 09/2002:
  • 260.40
  • F. References:
  • * DI 52150.020 - Offset Effective Date
  • * DI 52150.020 - First Possible Month of Offset
  • * DI 52105.001 - Reverse Offset
  • * RS 00615.770 - Combined Family Maximum limits
  • * RS 00601.123 - Special One-Time Payment for 12/99-6/01 (7/01 COLA)
  • * SM 00820.100 - Processing Dual/Triple Entitlement Cases
  • * RS 00615.201 - Reduced Spouse’s Benefits (and reduction factor fractions table)
  • * GN 02603.060 - Deduction-Before-Reduction Examples
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