DI 52160: Expedited Reinstatements with Workers' Compensation/Public Disability Benefit (WC/PDB)
BASIC (09-08)
A. WC/PDB payments continue through T8 period
The T8 month is the first month of substantial gainful activity (SGA) after the end of the 36-month extended period of eligibility (EPE) and any applicable grace months.
If WC/PDB payments continued through the T8 period, the same offset factors in effect prior to the T8 are used to compute offset, as follows:
Average current earnings (ACE)
Total Family Benefit (TFB)
Offset First Considered date
Eligibility year
NOTE: The new onset date and filing dates only determine the first month of EXR. These dates are not used to compute the PIA, the monthly provisional payment amount, or the amount payable after WC/PDB offset.
B. WC/PDB payments did not continue through the T8 period
If WC/PDB payments did not continue through the T8 period, you may need to establish a new offset first considered date and offset effective date (OED).
1. When a new offset first considered date applies
Establish a new offset first considered date if the original WC/PDB payments cease (i.e., entitlement to WC/PDB terminates) and a new WC/PDB claim is awarded (i.e., new injury/illness).
2. When a new OED applies
If the same WC/PDB claim (injury/illness) before the T8 also applies for the EXR, establish a new OED when:
WC/PDB payments stop for at least one calendar month and then resume; or
Offset does not apply for at least one calendar month due to high ACE, excludable expenses, or an interruption in WC/PDB payments.
A new OED is also established if the original WC/PDB payments cease (i.e., entitlement to WC/PDB terminates) and a new WC/PDB claim is awarded (i.e., new injury/illness).
3. Effect of a new offset first considered date
A new offset first considered date requires a new ACE and a new TFB.
C. How to compute the ACE in EXR cases
Regardless of whether WC/PDB payments continued through the T8 period, compute the ACE as follows:
Calculate the ACE based on the onset of the disability period that is being reinstated.
Consider recomputing a previous High-5 or average monthly wage (AMW) ACE if additional earnings could yield a higher ACE. See DI 52150.010 – Average Current Earnings (ACE).
D. EXR may involve a triennial redetermination (redet) of the ACE
Each year, claims involving WC/PDB offset are selected for a possible benefit increase due to a rise in the national earnings level. The redetermination of the ACE is often called a “redet.” In most EXR awards, a triennial redet ACE does not apply.
A redet of the ACE applies if:
the worker receives both DIB and WC/PDB payments; and
offset is continuous on the account through January of the year of the redetermination.
To determine the effective year of a triennial redet ACE, see DI 52150.080 – Triennial Redetermination (Redet) of Average Current Earnings (ACE).
T8 months are considered breaks in DIB entitlement and breaks in WC/PDB offset (i.e., offset is not continuous).
If the EXR start month is in a month after the T8 month, a break in entitlement (and a break in offset) has occurred. A new three-year cycle to determine the triennial redet year begins effective with the EXR OED.
In rare cases, the month of DIB termination is also the first month of entitlement to EXR. In these cases, a triennial redet may apply. For an example of when the T8 date does not constitute a break in offset because the EXR month is the same as the T8 month, see DI 52150.080 – Triennial Redetermination (Redet) of Average Current Earnings (ACE).
E. Processing EXR awards involving WC/PDB
1. Develop proof of WC/PDB
Obtain complete and up-to-date proof of WC/PDB. See DI 52145.001 - Obtaining Verification/Proof of Workers’ Compensation/Public Disability Benefit (WC/PDB) Information.
Route all WC/PDB documents for permanent retention. See DI 52145.015 – Retention of Workers’ Compensation/Public Disability Benefit (PDB) Proofs.
2. Enter WC/PDB data into the Interactive Computations Facility (ICF) program
Enter the WC/PDB data into ICF function #32 or #34. For instructions, see DI 52165.001- Using the Interactive Computations Facility (ICF) to Compute Workers’ Compensation/Public Disability Benefit (WC/PDB) Offset and ICF Terms.
Complete the following ICF screens:
WCPA Offset Options screen - Answer “Y” to the question “IS THIS COMPUTATION FROM AN A101/MANUAL AWARD?”
WCNM Notice Menu screen - Provide WC/PDB notice information used in connection with the EF101.
WCDA Disposition Adjudicate screen - Answer “Y” to the question “ADJUDICATE WC/PDB CLAIM?” When used with the EF101, this does not send the action to T2R for processing, but makes the offset computation available for MADCAP Direct Data Entry (MACADE) processing the benefit authorizer/benefit technical expert (BA/BTE).
NOTE: ICF function #32 determines if and when a triennial redet of the ACE applies.
3. Establish an electronic form 101 (EF101) amended award
Establish an amended award on the EFMenu screen. See coding instructions in DI 13050.060 – Expedited Reinstatement Awards – Title II.
Use the Account Data screen (EFACCT) screen in the EF101 screen path to annotate the WC/PDB data.
-
Enter the Type of Award Code (TAC) of D (disability) and answer the WC/PDB questions at the bottom of the EFACCT screen as follows:
WC/PDB INVOLVED (Y/N)? - Answer Y for all EXR awards when WC/PDB data coding is required.
WC/PDB OFFSET DATA ON ICF (Y/N)? - Answer Y when using ICF #32 or #34 to adjudicate an offset computation.
F. Related References
DI 13050.060 - Expedited Reinstatement Awards - Title II
MSOM T2PE 009.001- Electronic Form 101 (EF101) Processing
DI 52150.080 - Triennial redeterminations of the ACE
DI 52150.010 - Average current earnings (ACE)
DI 52150.005 - Total Family Benefit (TFB)
DI 52150.020 - Workers’ Compensation/Public Disability Benefit (WC/PDB) Offset First Considered Date and Offset Effective Date (OED)
DI 52150.055 - Protected Increases and Breaks in Workers’ Compensation/Public Disability Benefit (WC/PDB) Payments, Offset and Entitlement
RS 00605.005 - Benchmark Year (Eligibility Year)