TN 11 (11-12)

Citations:

20 CFR 416.325

A. Policy for determining an established onset date (EOD) for title XVI claims

1. Application Filing date is earliest possible EOD for title XVI claims

There is no retroactivity for title XVI payments. Therefore, the earliest possible EOD in a title XVI claim is the application filing date or protective filing date. However, we do consider the period before the filing date under certain circumstances, for example when determining if a claimant met the 12-month duration requirement. See DI 25505.025 Duration Requirements for Disability for information on applying duration to title XVI claims.

2. Filing dates, protective filing dates, and the title XVI EOD

The filing date for a title XVI application is the date the claimant files an application for title XVI benefits as defined in 20 CFR 416.325. A protective filing date establishes the earliest possible application date based on the claimant’s oral inquiry about SSI eligibility or a verbal or written statement of the claimant’s intent to file for SSI. The protective filing date is the earliest possible date the claimant can receive title XVI benefits. (See SI 00601.015.)

• If the claimant clearly meets the medical requirements for disability before the filing date and the exact onset date is known, the disability adjudicator must enter the earlier onset date on the Disability Determination and Transmittal (Form SSA-831).

• If the medical evidence does not support disability on or before the filing date, we use the date medical evidence supports disability as the EOD. This is a partially favorable allowance. See DI 25501.280 Notifying the Claimant of a Partially Favorable Allowance.

• If the claim is concurrent, adjudicators will enter the title II EOD for the title XVI claim, even if it is earlier than the filing date or protective filing date. If the title XVI filing date is earlier than the title II EOD (and the claimant met the medical and technical requirements for disability as of the filing date), adjudicators will establish an EOD under each title without regard to the other.

• In pre-release cases, we begin the title XVI application process several months before the claimant’s anticipated release from a public institution. (See DI 23530.000 for more information about pre-release claims.)

3. Title XVI payments and medical evidence

We cannot pay title XVI benefits prior to the filing date or protective filing date. Therefore, if the claimant is disabled, and meets all other eligibility requirements on that date, establish an EOD as of the filing date or protective filing date, unless medical severity clearly supports an earlier onset date. Documenting the onset date supported by the medical and other evidence may save resources in the future, by allowing us to adopt the determination to a subsequent claim without further development. (See DI 25501.370A.6. in this POMS section.) In most cases, it is not necessary to develop evidence before the filing date, unless this evidence is necessary to evaluate impairment severity or duration.

4. When to develop medical evidence prior to the filing date for a title XVI claim

The following situations require development of medical evidence prior to the filing date:

• If the requisite level of severity is currently established, but the claimant does not meet the duration requirement as of the filing date.

  EXAMPLE: If a claimant meets the medical criteria for disability as of the month of filing, but disability is expected to cease within 12 months of filing, we must show the claimant met the medical criteria for disability prior to the date of filing, to document that the impairment(s) lasted or is expected to last for at least 12 continuous months.

• The adjudicator cannot assess medical severity without medical documentation prior to the filing date.

  EXAMPLE: Ann filed for title XVI benefits on 05/15/2012, alleging disability due to carcinoma of the skin with metastases beyond the regional lymph nodes. Ann alleged her physician diagnosed her with skin carcinoma on 12/11/2010 and a biopsy performed on 01/18/2011 confirmed metastases beyond the regional lymph nodes. Ann’s earliest possible EOD for title XVI benefits is her filing date, which is 05/15/2012. However, we must obtain medical records from 01/18/2011 in order to determine if the severity of her condition met listing 13.02.A.

• There are dual title II and title XVI claims and the claimant alleges an alleged onset date (AOD) for the title II claim.

• There is an indication (e.g. remarks in the claims folder) that DDS needs to develop for a disability determination as of the date that the claimant’s special needs trust or pooled trust was established. See SI 01120.203 Exception to Counting Trusts Established on or after January 1, 2000.

5. Work activity and the 1619 work incentive

Section 1619 of the Social Security Act provides that we will not automatically cease title XVI beneficiaries with a disability for performance of substantial gainful activity (SGA). Generally, SGA determinations are required on initial claims. However, if a claimant qualifies for title XVI benefits as of the filing date, and begins performing SGA two or more months after being found disabled, the claimant may still qualify for title XVI benefits. If the claimant began performing SGA two or more months after the date of filing, but was found disabled as of, or prior to, the date of filing, we evaluate disability prior to the date of filing to determine if the claimant is protected by section 1619 work incentive provisions, as described in SI 02302.010B, 1619 Policy Principles, and SI 02302.030, Section 1619 Process and Procedures.

6. Other Considerations

• Establishing the earliest possible EOD may be beneficial to the claimant and be an expedient for adjudicators, if we determine entitlement for additional benefits later. For example, a claimant files an SSI claim at the age of 45 due to cerebral palsy with an AOD of birth. DDS establishes an onset date as of his date of birth. At the age of 51, the claimant files a Disabled Widow(er)s Benefit (DWB) claim. The FO or DDS may be able to allow the claim without making a new disability determination.

• Title XVI claims are subject to the reopening and revision provisions in DI 27505.001. Therefore, if the evidence suggests a prior claim can be reopened, it may be necessary to develop evidence before the current filing date.

B. Component roles for establishing onset for title XVI claims

1. Field Office (FO)

The field office provides the Disability Determination Services (DDS) with the claimant’s filing date and the protective filing date, if one exists, using a Disability Report—Field Office (EDCS 3367) or the paper Form SSA-3367

2. Disability Determination Services (DDS)

If all medical and eligibility requirements for disability are met, the disability determination service (DDS) establishes an EOD as of the claimant’s filing date. If there is a protective filing date, the DDS establishes an EOD as of the protective filing date.

C. Component instructions for establishing onset for title XVI claims

1. Field office (FO)

Follow the instructions found in DI 11005.045B.

2. Disability Determination Services (DDS)

• Secure medical and other evidence sufficient to determine if a fully favorable EOD is supported using the policy in DI 25501.370A in this section.

For concurrent title II and title XVI cases, establish the title XVI EOD as of the date of the title II EOD, unless the title XVI filing date is earlier than the title II EOD (as long as the claimant met the medical and technical requirements for disability as of the filing date). In that situation, establish an EOD under each title without regard to the other.

• When you use adjudicative judgment in establishing an EOD, you should explain your decision. In eCAT, put this explanation in the onset text box on the “Determination” page. If eCAT is not used, use an appropriate medical assessment form to document your decision and place it in section F of the electronic folder. Preparing an explanation will ensure your judgment is not substituted by third party reviewers. If the EOD is partially favorable, prepare a personalized disability explanation (PDE) that explains why you changed the EOD to be partially favorable. Send the PDE with an SSA-L1157–SI. (See DI 25501.280 Notifying Claimants of Partially Favorable Allowances.)