ISSUED: December 10, 1997
Childhood Disability Redeterminations
Pursuant to Pub. L. 104-193, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, as amended by Pub. L. 105-33, the Balanced Budget Act of 1997, SSA must perform a disability redetermination for beneficiaries under the age of 18 who were eligible for SSI based on disability as of August 22, 1996, and whose eligibility for benefits is based on an individualized functional assessment (IFA) or consideration of maladaptive behaviors in the personal/behavioral domain. The disability redetermination consists of a new determination of the individual's eligibility based on disability using the eligibility criteria for new applicants appropriate to the individual's age, except for rules pertaining to performance of substantial gainful activity (SGA). The medical improvement review standard (MIRS) does not apply. Individuals who are dissatisfied with the result of a childhood disability redetermination may appeal the reconsidered determination to the administrative law judge (ALJ) hearing level, and the hearing decision or dismissal to the Appeals Council (AC) level.
Pub. L. 104-193, as amended by Pub. L. 105-33, requires all SSI childhood disability beneficiaries who were eligible as children in the month before the month in which they attained age 18 to have their eligibility redetermined under the adult standards for initial claims either during the 1-year period beginning on the individual's 18th birthday, or in lieu of a continuing disability review, whenever the Commissioner determines that an individual's case is subject to redetermination. These disability redeterminations will be done using the adult disability criteria for initial claims except for the first step of sequential evaluation, SGA. The medical improvement review standard (MIRS) does not apply. Individuals who are dissatisfied with the results of the age-18 redetermination may appeal the reconsidered determination to the ALJ hearing level and the hearing decision or dismissal to the AC level.
The following instructions apply to appeals of childhood disability redeterminations or age-18 redeterminations pursuant to Pub. L. 104-193. Separate instructions will be issued for processing pending appeals of childhood cessation determinations issued prior to August 22, 1996.
OHA hearings and appeals of childhood disability redeterminations and age-18 redeterminations will be conducted under the usual regulations that govern the ALJ hearing and AC review procedures. See 20 CFR §§ 416.1444 ff. and §§ 416.1467 ff.
With the exception of special coding requirements and benefit continuation issues (see below), hearing offices (HOs) and the AC should process appeals of childhood disability redeterminations or age-18 redeterminations in the usual manner, applying the new childhood disability standard in childhood (under age 18) disability redeterminations (see 20 CFR §416.924 ff.) or the adult standards in age-18 redeterminations (see 20 CFR §416.920 ff.). These cases will have had an initial and reconsideration determination using the 1996 childhood disability standard (under age 18) or the adult standard (age 18), as appropriate. (Refer to memorandum from OHA Associate Commissioner dated June 6, 1997 and accompanying SSI childhood disability instructions).
The coding instructions for SSI childhood disability cases apply in these redetermination cases (refer to section VI. J., page 30 (HO level), and section VII. K., page 41 (AC level), of the instructions transmitted to OHA adjudicators on June 6, 1997.
Therefore, HOs must code these cases by entering into the Hearing Office Tracking System (HOTS) the regulation basis code and the impairment codes for all title XVI childhood disability redeterminations and age-18 redetermination cases. When the AC reviews a case and issues a decision, the appropriate regulation basis code and impairment codes must be entered into the OHA Case Control System. Sample coding sheets are included as Attachment 4 of the instructions dated June 6, 1997. Regulation and impairment codes are found in Attachments 3 and 5 of the instructions, respectively.
Statutory benefit continuation until the ALJ hearing decision is issued will be offered in redetermination cases where an individual's impairment is found to have ceased, not to exist or be no longer disabling and benefits would be terminated pursuant to a redetermination conducted under Pub. L. 104-193. Therefore, HOs are reminded that it will be necessary to follow established procedures to initiate payment termination, as appropriate. This requires sending the standard termination notification to the Social Security field office (FO) with a copy of the decision/order of dismissal. In cases when the ALJ finds that the claimant continues to be disabled and the AC issues a decision reversing the ALJ decision and finds that cessation has occurred, the AC must follow established procedures to notify the field office to terminate disability benefit payments.
In addition, when the AC remands a case to an ALJ for further proceedings, the prior ALJ decision or dismissal order is vacated and has no force or effect. Once a prior, unfavorable hearing decision or dismissal order is vacated, there is no longer any action to end eligibility for continued payments. When the AC remand is issued, if continued payments were previously being received at the ALJ hearing level in a medical cessation case, the servicing FO is responsible for taking necessary actions regarding reinstatement of continued benefits. However, the AC staff must follow established procedures to flag the case as a “Possible Title XVI Payment Continuation Case.”
“Good Cause” - Untimely Election
Many families with children who were receiving SSI disability benefits have received medical cessation notices in recent months and parents or guardians may not be timely seeking continued benefits within 10 days or appealing within 60 days of the date of the letter. Many adverse circumstances affect the lives of the families with children receiving these notices which will reasonably excuse the late filings. The longstanding “good cause” policy must be available to these individuals to protect their rights to appeal and to benefit continuation pending appeal.
When the issue of untimely election to continue benefits is presented at the hearing level, the ALJ must consider whether “good cause” exists for late filing for benefit continuation. The procedures for establishing “good cause” in HALLEX I-2-0-60 apply in this situation. In light of the critical needs of many of these claimants, “good cause” findings in benefit continuation situations should be made as expeditiously as possible. As with other situations in which a finding of “good cause” is required, disagreement by the beneficiary with a “good cause” determination or decision on a late-filed election is not an “initial determination” and does not provide a basis for further appeal (20 CFR §§ 416.1402 and 416.1403).
Hearing Office personnel should direct any questions concerning these instructions to their Regional Office. Regional Office personnel should contact the Division of Field Practices and Procedures in the Office of the Chief Administrative Law Judge at (703) 305-0022. Headquarters personnel should route questions to their Branch Chiefs who may contact the Office of Appellate Operations at 305-0106.