DI 25501: Onset
TN 11 (11-12)
A. Policy for the established onset date (EOD) for disabled widow(er) benefits (DWB) for Medicare claims
1. Established onset date (EOD) and deemed entitlement to disabled widow(er) benefits (DWB) for Medicare
We may deem certain widow(er)s whose DWB terminate upon entitlement to a non-disability benefit, or who elect to file for a higher non-disability benefit to be entitled to DWB benefits to establish entitlement to DWB-Medicare (see HI 00801.155). Deemed DWB enable the widow(er) to satisfy the 24-month qualifying period for Medicare based on disability without actually receiving cash disability benefits. The following widow(er)s may be deemed entitled to DWB benefits for the purpose of establishing entitlement to DWB-Medicare.
Beneficiaries entitled to mother’s or father’s benefits based on having a child in care.
Beneficiaries entitled to widow(er)’s benefits who are not, or were not, eligible for DWB prior to attainment of age 60.
Widow(er)s who become entitled to retirement benefits (based on attainment of age 62) or DWB (based on attainment of age 60).
2. Establish the EOD before the end of the DWB prescribed period
For a widow(er) to qualify for DWB-Medicare benefits on the earnings record of his or her deceased spouse, we must establish the EOD before the end of the prescribed period. (The prescribed period is defined in DI 25501.360A.4. in this section.)
3. Age considerations when establishing the EOD for DWB Medicare claims
For a claimant to qualify for DWB-Medicare benefits, we must establish the EOD before the age of 62 years and seven months.
EXCEPTION: For claimants with a documented diagnosis of Amyotrophic Lateral Sclerosis (ALS), commonly known as Lou Gehrig’s disease, we must establish the EOD before age 64 years and seven months, for the claimant to be eligible for DWB-Medicare benefits. Claimants diagnosed with ALS are not required to serve the 24-month qualifying period for Medicare. (For more information about ALS and Medicare entitlement, see DI 23580.001.)
4. Prescribed period for DWB-Medicare claims
We must establish the EOD no later than the end of the DWB prescribed period. The prescribed period begins with the latest of the following:
the month of the number holder’s death;
the last month of previous entitlement to DWB that terminated because disability ceased;
the last month of entitlement to mother’s or father’s benefits based on having a child in care (beneficiary identification code (BIC) “E” benefits).
The prescribed period ends with the earliest of the following:
84 months (seven years) after the prescribed period begins;
84 months after the claimant was last entitled to mother’s, father’s or widow(er)’s benefits;
the month before the month the widow(er) attains age 65 (for Medicare benefits only).
5. Controlling date for DWB Medicare claims
The field office (FO) determines the controlling date. The controlling date is the latest date we can establish onset without adversely affecting the first month of entitlement to DWB Medicare benefits. When determining the controlling date, consider:
the beginning date of the prescribed period,
the ending date of the prescribed period,
the retroactivity of the application,
the widow(er)’s age,
the alleged onset date (AOD), and
the widow(er)’s date of remarriage, if applicable.
An EOD on or before the controlling date is fully favorable. Therefore, adjudicators should focus development of evidence on establishing the EOD as of the controlling date. (For instructions concerning establishing the controlling date, see DI 11005.050.)
6. Waiting period for DWB Medicare claims and onset
Eligibility for DWB Medicare benefits is subject to a waiting period of five full consecutive calendar months. The waiting period begins no earlier than the later of:
the first day of the 17th month before the month of filing; or
the first day of the fifth month before the month the prescribed period began.
The claimant can satisfy this waiting period, in whole or in part, before the widow(er) attains age 60.
7. Medicare qualifying period for DWB Medicare claims and onset
In addition to the five full consecutive calendar month waiting period for DWB, there is a 24-month qualifying period for Medicare coverage based on disability (HI 00801.146). If the claimant meets all other eligibility criteria, he or she can satisfy up to 12 months of the Medicare qualifying period before the month of filing, even for widow(er) is receiving benefits based on having a child in care. In addition, months in which the claimant receives Supplemental Security Income (SSI) or federally administered State Supplementary Payments (SSP) count toward the 24-month qualifying period (see DI 11015.020).
EXCEPTIONS:
We waive the 24-month qualifying period for Medicare coverage for disabled claimants we medically determine to have ALS (see DI 23580.001).
In addition to Medicare based on disability (e.g., DWB-Medicare), claimants can become entitled to Medicare based on End Stage Renal Disease (ESRD). Unlike Medicare based on disability, ESRD Medicare is not subject to a qualifying period, as it does not require a finding that the claimant is disabled, as is required for Medicare based on disability. In some instances, the disability adjudicator may need to make a determination of the claimant’s disability, for purposes of establishing entitlement to DWB-Medicare, even though the claimant is already entitled to Medicare based on ESRD (see HI 00801.186 and HI 00801.258).
8. Marital status for DWB Medicare claims
Generally, a widow(er) must be unmarried in order to be entitled to DWB Medicare benefits. However, we may disregard a claimant’s remarriage if the remarriage occurs after attainment of age 50, if the widow(er) was disabled at the time of the remarriage (see RS 00207.003).
9. Chart for Establishing DWB Medicare Onset
|
If the Alleged Onset Date (AOD) is… |
And Disability Began… |
Then the Established Onset Date (EOD) is… |
|---|---|---|
|
In the past (before the controlling date) |
In the remote past (before the controlling date) |
The controlling date (unless we know the exact date), which is a fully favorable onset date |
|
In the past (before the controlling date) |
After the controlling date, but within the prescribed period
|
The exact date disability began, which is a partially favorable onset date |
|
After the controlling date but within prescribed period |
At the AOD
|
At the AOD – fully favorable |
B. Component roles and responsibilities for establishing the EOD for DWB Medicare claims
1. Field office (FO)
Establish a prescribed period, and
Establish a controlling date.
2. Disability Determination Services (DDS)
Develop medical evidence focused on establishing the EOD as of the controlling date.
C. Component instructions for establishing the EOD for DWB Medicare claims
1. Field office
Complete the EDCS-3367 “Onset” page and EDCS “Miscellaneous, DWB and prior filing” page following the instructions found in DI 81010.025.
NOTE: If the claimant remarried, use the Capability/Remarks page in the EDCS-3367 to annotate the date the claimant remarried.
For EDCS exclusion claims:
Calculate the prescribed period and controlling date using the instructions outlined in DI 11005.050.
Annotate the prescribed period and controlling date in block 6 of the Form SSA-3367.
2. Disability Determination Services (DDS)
Develop medical evidence focused on establishing the EOD as of the controlling date, or the AOD if later than the controlling date but within the prescribed period. If the EOD is not fully favorable, prepare a personalized disability explanation (PDE) explaining why we established the partially favorable EOD. Send the PDE with an SSA-L1157–DI. (See DI 25501.280 Notifying Claimants of Partially Favorable Allowances.)