Overview: The Process

Overview:

  1. CSR initial claims with caller/beneficiary, set up appt
  2. At the appt, the Claims Representative set up claims via (a) MCS and (b) eView
  3. DDS exams the claimant and make medical determination as to disability or not; sends letter.
  4. If deemed medically approved, the FO will review non-medical qualifications.
  5. If deemed “NOT” disabled, the beneficiary can appeal: recon, ALJ, ODAR. A new entries are setup in eView.

Redbook Example

02/14/2017

02/27/2017

06/7/2017

03/2018

08/2017

 

08/2019

 

  • Stopped working, alleged onset date (AOD)
  • Filed for concurrent benefits, both T2/SSDI and T16/SSIDI
  • Received award letter with onset date of 2/14/2017
  • SSIDI commence at $750/mo (Federal benefit rate, FBR, in 2018); Medicaid starts.
  • SSDI benefits start (Entitlement date = Onset date + 5 months). Total benefits $770 = $300 in SSDI and $470 in SSIDI. SSIDI: 750 – (300 SSDI + 20 general income exclusion)
  • Medicare starts (Entitlement date + 24 months). Part A is free. Part B is 134/mo.  Since CLMT is eligible for SSI, the state pays for Part B (state buy-in)
01/2022

 

09/2022

10/2022

 

 

 

 

 

12/2022

  • Returns to work, earns $2,000/mo (1,800 value and 200 employer subsidy).
    • TWP begins for SSDI
    • SSI stops due to earnings
  • TWP ends (9 months: J- F-M-A-M-J-J-A-S)
  • Extended Period of Eligibility (EPE) begins after TWP ends. For the next 36 months (EPE= 10/2022 + 36 months = 9/2025). Work at SGA continues.

SSDI benefits cease, (3 months) grace months for payment are 10/2022-12/2022.

SGA?  CLMT pays for his work transportation of $350/mo. There is a medical need for him to take a taxi. SSA deducts the cost of his transportation expenses as impairment-related work expenses (IRWE). SGA = 2000 – 200 -350 = 1,450, which is over the SGA level of 1,180 for 2018.

  • Grace months for payment are 10/2022-12/2022 or 3mos
01/2023

09/2025

09/2025

10/2025

07/2030

09/30/2030

  • SSDI benefits stop
  • EPE ends (starts 10/2022 + 36 months = 9/2025)
  • Extended Medicare begins
  • SSDI termination month. Medicaid ends if earnings are over state threshold amount. Entitlement may stop earlier than October 2025 if he no longer meets our disability requirements.
  • Extended Medicare stops = TWP + 93mos = 9/2022 + 93mos = 07/2030. May be able to purchase Premium HI and/or buy into Medicaid
  • Last month to file for EXR if no longer working and still disabled

Terms:

  • Alleged onset date (AOD)
  • Blind Work Expenses (BWE, vs IRWE)
  • Concurrent: filing for both T2/SSDI and T16/SSIDI
  • Extended Period of Eligibility (EPE) = TWP + 36mos = Sept 2022 + 36mos = Sept 2025
  • EPE consists of 36mos during which a beneficiary may receive a full cash benefit for any
  • month the person does not perform Substantial Gainful Activity (SGA). As long as the individual continues is disability, their entitlement to benefits doesn’t fully terminate until EPE ends. [DI 13010.215]
  • Expedited reinstatement (EXR): see discussion follows.
  • Extended Medicare = TWP + 93mos = Sept 2022 + 93mos = July 2030. 93 mos = 7 years, 9 months
  • Grace period = TWP + 3mos = Sept 2022 + 3 mos = Dec 2022
  • Substantial gainful activity (SGA)
  • Impairment-related work expenses (IRWE vs BWE)
  • SSDI
  • SSIDI
  • Trial Work Period (TWP) = 9 months. Ends Sept 2022

– – – –
Given: SGA in 2018 is $1,180
ref: https://www.ssa.gov/redbook/eng/supportsexample.htm

NOTE. How does the claimant’s work activity affect his SSI benefit (Title XVI)?
SGA rules are different for SSI. For SSI disability benefits, we only consider SGA when the initial claim is filed (unless the disability is blindness, then we do not consider SGA at all). We do not consider SGA after a person becomes eligible for SSI. However, we must determine whether the person continues to meet the non-disability requirements, including income and resources. We determine the effect of the claimant’s earnings on his SSI eligibility and payment amount on a month-by-month basis.

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