TN 16 (09-95)

Citations:

Mazza v. Secretary of Health and Human Services, 903 F. 2d. 953 (3rd Cir. 1990)

A. Policy

1. General

The Court of Appeals in the Third Circuit ruled on May 17, 1990, that, in concurrent title II/title XVI allowances, eligibility for title XVI benefits must be adjudicated before the retroactive title II benefits are paid. SSA published an AR on January 10, 1992, stating that SSA will apply title II offset in concurrent cases in the Third Circuit. The effect of the court's decision is to ensure that Medicaid for the retroactive period of title XVI eligibility is not denied solely because of title XVI offset.

2. How We Will Comply

In all concurrent title II/title XVI cases in the Third Circuit, adjudicate the title XVI claim before the retroactive title II benefits are paid. These claims will be SPORT exclusions.

NOTE: For claims processed after 9/08/95, the SSR/MBR interface will control the release of retroactive title II benefits after the title XVI is paid. Therefore, it will no longer be necessary to exclude these claims from the automated process.

3. Who Is Affected

SSA must adjudicate the title XVI claim before the retroactive title II benefits are paid for all claimants who reside in:

• Delaware, New Jersey, Pennsylvania or the Virgin Islands at the time a determination or decision is made at any adjudicative level (i.e.; initial, reconsideration, ALJ or AC), and

• Applied for benefits under title II and title XVI.

B. Procedure — Processing Title II/XVI Claims 09/08/95 or Later

NOTE: Effective with claims processed 9/08/95 or later, the interface of the MBR/SSR will control the release of retroactive title II benefits after the title XVI has been paid.

Process the cases normally — that is, input the title II claim with the WF FAC code and allow the system to process payment of the retroactive benefits. These cases will no longer be SPORT exclusions.