TN 4 (06-05)

A. Policy

1. Deemed Initial Determinations

Deemed initial determinations are based on the assumption that the recipient's circumstances remain the same as in the prior month. An initial determination is deemed to occur (i.e., no notice is sent) on the first of each month that a recipient is shown on the record as eligible and payment amount remains unchanged. A deemed determination cannot occur in any month that is an effective month of a notice of an initial determination. See SI 04070.030B. and SI 04070.040F. for an explanation of effective months of initial determinations with notices.

Based on this definition of deemed initial determinations, there are no deemed determinations for any months in which payments are not received; e.g., a period of suspension. (See SI 02301.201B.1. – Description of Posteligibility Events and SI 02301.205 – Suspension and Reestablishing Eligibility, for a definition of “suspension.”

NOTE: Erroneous Death Determinations: Although no notice is issued with a death determination, it is not a deemed initial determination. See SI 04070.080B. for proper treatment of erroneous death determinations.

2. Deemed Initial Determinations - Effective Months of Notices

Deemed initial determinations are important in that they allow the Agency to effect change for past months that are not governed by written notices of initial determinations. Therefore, it is important to identify months for which there is a deemed initial determination and months for which there is an actual written initial determination.

REMINDER: The concepts of deemed initial determinations and effective months of notices of initial determinations apply only for purposes of administrative finality with respect to nondisability issues. They do not apply to disability determinations.

B. Policy – Initial Determinations – Effective Months of Notices

When a notice of an initial determination is issued, the months with actual (as opposed to “deemed”) determinations are specified in the notice. If the award notice specifies months in the future only, the first month specified is the only initial determination covered by the notice. (See example SI 04070.030C.1.) If the notice is an award notice covering months in the past as well, the date of the notice is the initial determination date for all months from the first month through the last month specified in the notice. All payments made following the last month specified in the notice are subject to deemed initial determinations and are made in the same amount as the payment in the last month mentioned in the notice. (See example SI 04070.030C.2.)

Changes in eligibility or payment determination for past months: When a notice changes the eligibility or payment determination for past months, but not the current or future months, it is a notice of a revised determination for these months, not a notice of an initial determination. (See example SI 04070.030C.3.)

C. Examples of Effective Months and Deemed Initial Determinations

1. Example: The notice specifies only months in the future

An award notice dated February 15, 2003 which explains ongoing payments beginning March 1, 2003 has an effective month of March. The first deemed determination is April 1, 2003.

2. Example: An award notice specifies months in the past as well as the future

An award notice dated June 16, 2003, which explains that payments are effective with January 1, 2003 and continuing, has effective months of January 1, 2003 through July 2003. The first deemed determination is August 1, 2003.

3. Example: The notice specifies changes in eligibility or payment determination for past months

An individual reports on February 5, 2003 that he has begun receiving an extra $30 a month in his pension check beginning with the current month. The individual receives a Notice of Planned Action dated February 12, 2003 that says his SSI check will be reduced by $30 as of April 2003. This notice is a revised initial determination with an effective month of April 2003. Deemed initial determinations begin once more with May 1, 2003.

D. Procedure – Reopening Situations

1. Determining the Date of the Initial Determination

The date of an initial determination is important because in most instances reopening is possible only within one or two years of this date. This is true even if the initial determination has been appealed.

2. Notice Sent

When a notice of an initial determination is sent, the date of the notice is the date the initial determination was made.

Careful interviewing regarding the issues being questioned permits identification of the appropriate notice. Also consider the following in determining the date of the notice:

• When the notice was issued by the system, determine the date of the initial determination from the Online Retrieval System (ORS). Automated notices are dated seven calendar days after the corresponding systems run date in the NOTC field of the SSR. (See NL 00801.005 – Systems Generated Notices. See MSOM ORS 003.001 – TNA Online Notice Retrieval System for an explanation of ORS.

• When there is a manual or automated overpayment notice, the date can be obtained from the Overpayment Sequence Data Segment (OPSQ) (See SM 01601.880 – Overpayment Sequence Data – OPSQ).

3. No Notice Sent

When there was no notice of the initial determination, determine the date of the determination as follows:

a. Deemed determinations

For deemed determinations, the date is the first day of the month.

b. Erroneous death determinations

For erroneous death determinations, the date is the date that the erroneous date of death was input to the SSI system.

NOTE: If no notice was sent and one should have been, the individual may establish good cause for late filing of an appeal. See SI 04020.020B.3. for an explanation of good cause.

E. Examples of Calculating the Period Subject to Reopening

1. Example

A denial notice is issued June 18, 1999. This determination cannot be reopened after June 18, 2001 (24 months later) for good cause.

2. Example

On February 2, 1999 an FO learns that an SSI recipient was residing in an institution where N02 should have applied for November 1996 through July 1997. The FO must determine the earliest deemed initial determination it can reopen and revise. The FO counts back 24 months to February 2, 1997. The first deemed initial determination coincident to or after February 2, 1997 is March 1, 1997.

3. Example

On May 12, 2003, SSA discovered that a SSI recipient had changed his living arrangement on February 22, 2000 causing an overpayment. Because the Agency did not find fraud or similar fault, the overpayment assessment is limited to 24 months from June 2001 to May 2003. The first deemed initial determination that can be made based on the discovery date of May 12, 2003 under the 2 year good cause rule is June 1, 2001.

4. Example

On January 5, 2002, SSA discovered, through a computer match, that a recipient began receiving an annuity in September 1999. SSA did not find fraud or similar fault. The first deemed initial determination based on the discovery date of January 5, 2002 is February 1, 2000. The period that can be reopened and revised according to administrative finality is February 2000 through January 2002.

F. Procedure – Adjusting for Retrospective Monthly Accounting (RMA)

When you reopen and revise initial determinations within the one-year or two-year rule and income issues are involved (including in-kind support and maintenance-income types H and J), take RMA into account when changing the payment determination for months at the beginning of the administrative finality period. In order to change the payment due for the first two months of the period you may have to change the income recorded in the budget months, even if there is excess income in one of those months.

If you must input or remove excess income for a budget month, take action to prevent the system from acting on any resulting overpayment or underpayment for the budget month. Use the PS M02, force due process, to reconcile the record. (See MSOM BUSSR 002.006 – Force Due Process for the procedure and SM 02101.250 – How the System Computes a M02 Record for an explanation of the computation process).

1. Budget Month Income Creates an Incorrect Overpayment

If budget month income will create an overpayment in the budget months barred to correction, input the excess income, suppress automated notices, and wait for the record to compute the overpayment. Then use the PS M02, force due procedure, to change the due amount on the SSR to the original amount so that the overpayment is zero. Once the record has been placed in PS M02, terminate that record and establish a start date record. Issue manual notices as appropriate.

2. Budget Month Income Creates an Incorrect Underpayment

If budget month income creates an underpayment for the budget months barred to correction, enter the excess income and post a “U” TAC. Wait for the transaction to process in order to determine the amount of the underpayment. Delete the “U” TAC and use the PS M02, force due process. Change the due amount so that the underpayment for the record is correct. Once the record has been placed in PS M02, terminate that record and establish a start date record. Issue manual notices as appropriate.

G. Examples – Budget Month Income

Although the examples involve deemed initial determinations, RMA could also be a consideration in a case involving an actual determination.

1. Example - Budget Month Income Creates No Mispayment for the Barred Months

On June 15, 2003, the FO learns that Ms. C. had $30 more income than shown on her record beginning with January, 2001 and continuing, but she remains eligible throughout. The earliest determination the FO can reopen and revise is the July 1, 2001 deemed initial determination. To change the payment amount for July 2001 and August 2001, the FO must input the correct amount of income received in May 2001 and June 2001. The input in this case is straightforward; the eligibility and payment determinations for months before July 2001 are not affected by the changes to the budget months.

2. Example - Budget Month Income Creates an Incorrect Overpayment

Bobby K. is a disabled child who lives with his mother. At a redetermination conducted in the office on June 15, 2003, the FO learns that Bobby's mother has been working since May 2001, making enough in some months to make Bobby ineligible. (The earliest month the FO can revise the determination for is July 2001.) In May 2001, Bobby's mother worked a lot of overtime and her deemed income caused Bobby to exceed the income limit. In June and July, she didn't earn that much and Bobby is eligible for these months. The wages fluctuate each month, but he isn't ineligible again until December 2001. Although the wages for May and June must be input to correct the payment determination for July and August, this creates an erroneous overpayment for May and June, which are barred from correction. Therefore, the FO suppresses the automated notices and after the system computes the overpayment, the FO places the record in force due (PS M02) to change the due amount. The FO then terminates this record and starts a new one. The FO also prepares an SSA-L8155-U2 (Notice of Planned Action) and an overpayment notice because the automated notices were suppressed.

3. Example - Budget Month Income Creates an Incorrect Overpayment in the Budget Months Barred to Correction

On April 13, 1999, SSA staff initiated a redetermination. At that time, the Agency discovered that the individual was receiving more income than was previously reported but did not find fraud or similar fault. Consequently, SSA staff reviewed the period from March 1997 to March 1999, which was within 26 months. Under administrative finality, May 1997 is the earliest month that can be revised. Since budget month income will create an overpayment in this case, SSA should input the excess income, suppress automated notices, and wait for the record to compute the overpayment. Then, SSA should use the force due procedure (PS M02) to change the due amount on the SSR to the original amount so that the overpayment is zero for the 2 months (March & April) which are barred to correction. Once the record has been placed in PS M02, the record should be terminated and a start date record should be established. (See SI 04070.030F., MSOM BUSSR 002.001 E, and SM 02101.250.)

4. Example - Budget Month Income Creates an Underpayment

Based on a Federal benefit rate of $500 and countable income of $480, Mr. D. was receiving $20 in SSI each month. At a redetermination interview on June 15, 2003, Mr. D. reported that in May 2001 a friend gave him $1,000, making him ineligible in that month. At the same time, he stopped taking meals at his parents' house (May 2001 was the last month he received this income). This in-kind support and maintenance was valued at $50 on the SSR. The FO determines that the earliest month for which the determination can be revised is July 2001 and so inputs the receipt of the $1,000 income in May 2001 and removes the $50 income for June 2001 on so that payments for July 2001 and continuing will be computed correctly. However, these inputs will create an overpayment for May 2001 and an underpayment for June 2001 with a net underpayment for these two months. Because the underpayment for these two months is incorrect, the FO places a “U” TAC on the record when it inputs the income changes. Once the system has computed the underpayment, the FO deletes the “U” TAC and places the record in PS M02, force due, to change the due amount so that the total underpayment on the record does not include the amount for May and June of 2001. The FO issues an SSA-L8151-U2 (Notice of Change in Payment).

H. Process – Requesting Prior Folder

If it is necessary to request the folder per the instructions, see SM 01201.205 – SSI Folder Recall. See SI 04070.010G. for an explanation as to who may reopen which determinations or decisions.

1. FO Is Reopening

If any new evidence and a review of the systems record are sufficient to determine whether a revised determination is appropriate, do not request the folder to conduct a folder review. If these are not sufficient to determine whether a revised determination is appropriate, and a review of evidence in file is required, request the folder and determine whether evidence permits current eligibility or an increase in payment amount. If so, do whatever is appropriate to begin payments or increase the current payment amount until the folder is received. This could mean taking a new application if current eligibility exists and determining whether reopening is correct later when the folder is received.

2. The Appropriate Level for Reopening Is ALJ or AC

If the appropriate level for reopening is the ALJ or AC, the ALJ or AC may require the folder before deciding whether to reopen and revise the prior decision. Obtain the folder, incorporate in the folder any new evidence, and forward the folder to the ALJ or AC, as appropriate. The ALJ or AC will notify the claimant if the decision is reopened or if reopening is denied.

I. References

SI 02305.034 – Period of Review RZs and LIs

SI 02005.001 – Retrospective Monthly Accounting Computation

NL 00801.010 – Manually Prepared Notices