SI 04030.050: The SSI Hearing Decision

changes
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~~Effective Dates: 01/17/2018 - Present~~
Effective Dates: 01/19/2018 - Present
BASIC (12-93)
SI 04030.050 The SSI Hearing Decision
A. Policy — Fully Favorable Decision Without Hearing
If the evidence in the hearing record supports a decision in favor of the appellant and all parties on every issue, the ALJ may issue a decision without oral hearing. The notice of decision will inform parties of their right to an oral hearing and to examine the evidence on which the decision was based.
B. Policy — After The Hearing
1. Distribution After Hearing
Unless the hearing request is withdrawn or dismissed, the ALJ will usually make a decision or, if appropriate, send a recommended decision to the AC after the hearing. If the ALJ renders a favorable decision on a nonmedical factor in a disability or blindness claim which was disallowed on that nonmedical factor, he/she may return the case to the FO to forward to ODIO or DDS for a determination on the medical factor.
If the ALJ issues a decision, the FO is advised of the ALJ action by a copy of the decision.
2. Distribution of the Decision Notice
* When the ALJ releases copies of the decision or order to the appellant, the RO, the FO, the PSC and ODIO, as appropriate, the HO forwards the file to the component responsible for effectuating the ALJ decisions in the regions or to Office of Hearings Operations (OHO) Headquarters, as appropriate.
* The FO and the PSC, or ODIO, if involved, must input the decision and update the case control system.
* If the ALJ affirms a disability cessation or dismisses the hearing request, and the appellant is in continuing pay status under a protected payment level provision, the HO (or OHO) will annotate the FO copy of the decision “TERMINATION NECESSARY” and annotate the HA-505 route slip “TERMINATION INPUT NEEDED.”
3. ALJ Oral (Bench) Decisions
ALJ oral (bench) decisions are abbreviated fully favorable decisions that are entered into the record of the hearing proceedings and provide an alternative procedure for the ALJ to use instead of the usual multi-page, formal ALJ decision. Oral (bench) decisions may be used for initial adult disability cases, and only when the ALJ decides that the case will be fully favorable. See DI 12010.041 for guidance for processing wholly favorable ALJ oral (bench) decisions.
4. ALJ or AC Decision Affected by New Legislation or Change of Position
a. Nonmedical Cases
The case must be forwarded to the RO for a discussion of the matter with the OHO, Office of Appellate Operations and ODISP, OISP, Office of Program Benefits.
b. Medical Issue in Blindness or Disability Case
The case must be forwarded to the RO for a discussion of the matter with the OHO, Office of Appellate Operations and ODISP, Office of Disability Programs.
c. New Legislation Makes Claimant Immediately Eligible
A claim must be taken and payments must be awarded immediately. The complete folder must then be sent to the RO, ARC, Programs with the ALJ decision, for discussions with ODISP and OHOHeadquarters as in SI 04030.050B.3.a. and SI 04030.050B.3.b.
A claim must be taken and payments must be awarded immediately. The complete folder must then be sent to the RO, ARC, Programs with the ALJ decision, for discussions with ODISP and OHO Headquarters as in SI 04030.050B.3.a. and SI 04030.050B.3.b.
5. Materials Submitted At or After Hearing
Because the ALJ encourages the appellant to submit photostatic or certified copies of evidentiary records for the hearing record at or after the hearing, such documents must be placed into the claims folder unless copies are made, and the originals are returned to the appellant.
NOTE: See C.11. below if the dissatisfied appellant submits new evidence after the hearing is closed.
6. Favorable Hearing — Requirement to Reopen
If the appellant has received an unfavorable determination or decision on a prior application and the ALJ decides to rule favorably on the current application, the ALJ may reopen and revise the prior determination or decision, if appropriate. However, the ALJ may issue a favorable decision on a current application but inadvertently not reopen a prior denial.
During the effectuation, the existence of all the following conditions will require reopening and revising the denial of a prior SSI determination on an application or a cessation:
* The ALJ establishes that a factor of eligibility was met continuously on or before the date of the prior initial denial notice; e.g., the claimant is determined to be disabled or blind, over 65, or met the resource limit, etc., on or before the date the prior denial, termination or cessation notice was issued; and
* The prior denial/cessation and the current hearing decision involve the same factor of eligibility; and
* In the decision on the current application, the ALJ did not refuse to reopen the prior denial; and
* There is no ALJ, AC or court decision on the prior denial/ cessation; and
* The date of initial denial notice for the prior application/ cessation is within 2 years before the date the claimant filed the subsequent application. (See SI 04070.005A.9. for a definition of “affirmative action” in writing.)
7. Favorable Hearing Decision — Reopening When There Are Intervening Months of Nonpayment
a. Nonappealed Issue
For factors of eligibility other than the issue appealed, the claimant need not be eligible in every month since the date of the prior application/ cessation.
EXAMPLE: If the ALJ decided the issue of disability, the claimant need not meet nondisability issues for every month between the date of the prior application and the date of the post hearing update (see SI 00603.036 and SI 00603.035 regarding updates and procedures after a medical allowance).
b. Appealed Issue
The ALJ's decision may indicate eligibility on or earlier than the date of the prior denial. However, other evidence may indicate the claimant is not eligible, based on the issue appealed for 1 or more month(s), between the date of the prior application and the date of the current application.
In this case, the prior denial must not be reopened since the criterion in section B.5. (a factor of eligibility must be met continuously on or before the date of the prior initial denial notice) is not established. The ALJ or the Appeals Council must review and reopen the ALJ's decision, if appropriate, per SI 04030.060A.2.
8. Favorable Hearing Decision — ALJ Reopens Prior Denial
a. 2-Year Rule
If the ALJ improperly reopens a prior denial made more than 2 years before the current application, the resulting ALJ decision is final if it is not appealed timely or if the AC does not review on its own motion. The hearing decisions in such cases must be effectuated. See SI 04030.050C.8. for procedures to follow in cases of erroneous reopenings.
b. AC “Own Motion” Review
To review a decision on its “own motion,” the AC must decide to review the decision within 60 days after the date of the hearing decision.
C. Procedure
1. Effectuating Hearing Decisions
* Read the entire ALJ decision to determine if the appellant's payment status should be changed or adjustments should be made per SM 01305.500 to SM 01305.800 under the statutory disability payment continuation provisions.
* If the decision is an affirmation of a medical/blindness cessation, a dismissal for abandonment, or a withdrawal following such cessation, query the system for payment status of title II and title XVI benefits.
* In all ALJ decisions, make the SSA-8028 (SSI Claims Control) input and MSSICS online appeal systems input to record the location of the folder and the status of the appeal.
NOTE: It is important to make all appropriate systems inputs when effectuating any ALJ decision.
NOTE: Regional variations exist for control and effectuation of ALJ decisions. (See SM 01010.062A for escalated cases.)
2. Effectuating Affirmations and Dismissals of Nondisability Cases
Do not send the appellant a notice of the unfavorable decision, since the HO will assume sole responsibility for notifying the appellant of the unfavorable decision. The HO will send the folder to the Social Security Office National Records Center.
~~NOTE: The HO will send the folder to OHO Headquarters for retention during the time for requesting review of hearing decisions.~~
3. Effectuating Affirmations and Dismissals of Disability Cases in Current Pay
* On receipt of a copy of the decision and a memorandum which requests termination of benefit continuation payments, query the SSR to verify payment continuation status and then take systems action to terminate payments. If the ALJ finds disability ceasing in a later month than was determined at the initial level, terminate payments accordingly.
NOTE: The ALJ will annotate the Form HA-5051-U3 (Decision or Dismissal by Administrative Law Judge) to reflect when the FO should terminate continuing payments.
* In title II/title XVI payment continuation cases, obtain an MBR query effective with the month the disability ended. If the claimant is currently receiving title II payments, notify the appropriate office (ODIO or the PSC) immediately of the unfavorable decision.
* Identify the payment continuation cases with a stamp “TERMINATION INPUT NEEDED” on the decision routing Form HA-5051.
* If disability payments are continuing, terminate the title XVI payments on the basis of the FO copy of the hearing decision or dismissal or the ALJ's memorandum requesting termination of those payments. The HO forwards the folder to the SSANRC.
* If the HO staff has not done so, annotate the FO copy of the hearing decision or dismissal in payment continuation cases “TERMINATION NECESSARY.”
4. Effectuating Affirmations and Dismissals of Disability Cases Not in Current Pay
* On receipt of the decision, take action to record the medical/ blindness cessation on the SSR.
NOTE: The HO will also specifically annotate disability cessation affirmation decisions in which payments are in suspense for nondisability factors; e.g., excess resources. In such cases, the HO will annotate the FO copy of the hearing decision or dismissal “SSR Input Necessary.” The routing form HA-505 will further identify such cases with the note “SSR Input of Medical/Blindness Cessation Determination Necessary.”
* If disability payments have already been terminated because the appellant did not request a hearing (and continued benefits in medical cessation cases) within 10 days of receipt of the cessation notice, annotate the FO copy of the hearing decision or dismissal “SSR Input Necessary.” Record the hearing decision or dismissal on the SSR and update the MSSICS online appeal system.
5. Effectuating Reversals in Current Pay — Responsibility of the FO
Upon receipt of a hearing reversal claims case in which payments have been continued in order to meet the statutory disability payment continuation requirements from the HO, update the SSR to reflect the favorable decision at the hearing level.
NOTE: In title II/title XVI reversals, the HO will send the title II folder to ODIO or the PSC.
6. Effectuating Reversals Not in Current Pay
a. Forwarding the Title II Case Folder
Forward a title II folder which has been erroneously routed to an FO by a HO to ODIO or PSC in the same manner as other title II folders, rather than returning it to the HO.
NOTE: The responsibility for controlling fully or partially favorable title XVI hearing decisions in all SSI initial and PE nondisability (and disability cases in which payments have been stopped) rests with the FO.
b. Effectuation Functions of the FO
* Conduct a preliminary review of the case; and
* Forward disability/blindness cases with potential drug addiction or alcoholism involvement to the Disability Quality Branch (DQB) in the Field Assessment Office in the RO; and
* Prepare Form SSA-8028 (SSI Claims Control) to update the SSICS establishing folder controls when cases are received and dispatched; and
* Establish the case controls for timely effectuation of hearing decisions; and
* Update or develop factors of eligibility not decided in the hearing. See SI 00603.002 if the case was processed under the OHO early notification procedure. See SI 00603.036 for other simultaneous development cases and SI 00603.035 for other deferred development cases.
c. After Effectuation of a Favorable Hearing Decision on a Disability Case
Forward the folder under regional procedure to the Disability Review Section (DRS) or DQB for determination of the need to establish a medical reexamination diary.
NOTE: If the case meets the criteria for a medical reexamination, the DRS or DQB will establish the diary.
NOTE: To effectuate payment before the need for a medical reexamination diary is determined, input a temporary code of N00103 in the MO field.
d. After Action By the DRS or DQB
Return the folder to the FO. Do not wait for the return of the folder before effectuating payment.
7. Favorable Hearing Decision — FO Reopens Prior Denial
a. Making A Reopening Determination
As soon as you find a prior denial or cessation that can be reopened, prepare a reopening determination on an RC showing the dates of the prior application, denial, reopening, and that the same eligibility factor is involved.
NOTE: The determination sets the affirmative action in writing date (See SI 04070.015B. for an explanation of affirmative action in writing).
b. Documentation
Obtain the prior folder. If there is no prior folder, obtain an SSID. Make sure the prior denial and the current hearing decision involve the same factor of eligibility. If it is not clear that the same factor of eligibility is involved, ask the Appeals Council to review and reopen the ALJ's decision per SI 04030.060.
c. Development
See SI 00603.035 for update procedures and effectuation. Issue a notice as described in DI 12010.035 and DI 12010.040.
d. Eligibility For Title II
If reopening a prior denial may affect eligibility under title II, follow DI 27515.010 in disability cases or GN 04010.001 for nondisability cases.
8. Favorable Hearing Decision — Request For AC Review
a. Within 45 Days, FO Discovers ALJ Decision Improperly Reopening Prior Denial
To allow time for AC action within the 60 day limit, you must discover an improper reopening within 45 days after the ALJ decision. If you find an improper reopening within that time, call the Programs Staff in the RO. If the RO agrees the prior denial was reopened improperly, send the folder to the Deputy Director, Office of Appellate Operations, OARO, OAO, 5107 Leesburg Pike, Falls Church, VA 22041-3255 via route slip. Annotate on the route slip:
* “AC review requested per Regulation 416.1469. Hearing decision reopened prior denial over 2 years old. Regional memorandum to follow.”
When the RO sends a memorandum per SI 04030.060B.2., pay the claim prospectively. Withhold retroactive payment on the improperly reopened application until the AC responds to the RO memorandum.
b. FO After 45 Days Discovers ALJ Decision Improperly Reopening Prior Denial
Effectuate payment effective with the date determined by the ALJ's favorable decision if:
* The ALJ reopened a prior denial more than 2 years old; and
* You did not discover the error in time to permit AC “own motion” review.
IMPORTANT: The 60-day AC review limit is the regulatory limit for initiation of “own motion” review. The 45-day deadline is a practical goal. The 45-day goal can be revised by regional arrangement between the RO, ARC, Programs and OAO (OARO) staffs provided the AC has time to meet the 60-day regulatory limit.
9. Notice to Appellant of Action on ALJ Decision
Prepare and send an award notice using an SSA-L8165-U2 (Important Information). See POMS NL 00802.010 through NL 00802.015 for instructions on preparing an award notice. Also see the SSI initial notices menu of the Distributed Online Correspondence System (DOCS).
Prepare an SSA-636-U3 and annotate: “Decision Effectuated.” Attach a copy of the award notice and send both to the hearing office directed to the attention of the ALJ.
10. Appellant Dissatisfied With ALJ Decision
* If the appellant expresses dissatisfaction with the decision in a letter, send the letter to the AC after preparing an HA-520-U6 (Request for Review of Hearing Decision/Order) (see GN 03104.300 and SI 04040.020C.6. for instructions on completing Form HA-520-U6).
* If the appellant orally expresses dissatisfaction with the ALJ's decision, find out if he/she wants an AC review. If so, assist him/her in completing an HA-520-U6 and send the completed form with any material obtained to the AC. (See SI 04040.020C., for instructions.)
11. Additional Information and Evidence Received After Hearing
Evaluate new information received in the FO after a hearing decision.
a. If the Evidence is Pertinent and Bears on the Same Issue and Period Ruled on By the ALJ
Forward to the ALJ if:
* No request for AC review of the ALJ's decision was filed and the AC did not review the decision on its own motion; or
* A request for review was filed but the AC dismissed it for any reason other than the death of the appellant; or
* A request for review was filed but the AC denied it and the 60-day period for filing a civil action has expired; or
* The ALJ dismissed the hearing request and, the dismissal has not been vacated, and material relates to the reason for dismissal.
Forward the entire folder, including the new evidence, to the AC if:
* It issued the decision; or
* It dismissed a request for review because of the death of the appellant; or
* It denied a request for review but the 60-day period for filing a civil action has not expired; or
* The appellant or representative is filing a civil action after the 60-day time limit and brings or sends to the FO information and a statement to establish good cause for late filing.
b. The Material is Substantive But Does Not Bear On the Issues Decided By the ALJ
Evaluate the evidence and determine the appropriate action (e.g., redetermination, notification for payment suspension, etc.).
c. The Material is Extraneous or Duplicative
Associate it with the folder.

POMS Reference

SI 04030.050: The SSI Hearing Decision