I-2-8-7.Continuation of Disability Payments in Medical Cessation Remand Cases

Last Update: 10/24/14 (Transmittal I-2-123)

A. General

If the Appeals Council (AC) remands a case for further action, the administrative law judge's (ALJ) decision or dismissal order issued on a medical cessation appeal is vacated and is no longer in effect. Continued benefits, however, are payable pending a new decision by the ALJ or final action by the AC on the ALJ's recommended decision.

If a claimant and/or his or her auxiliaries previously elected to receive continued benefits pending the ALJ's decision, the agency will automatically restart the benefits. If the claimant and his or her auxiliaries did not previously elect to have benefits continued pending an ALJ decision and they now want to elect continued benefits, they must request to do so no later than 10 days after they receive our notice telling them about continued benefits. The agency will send the claimant and auxiliaries appropriate notices. See 20 CFR 404.1597a and 416.996.

B. Notices - Title XVI-only and Concurrent Cases

When the AC remands a title XVI-only or concurrent (titles II and XVI) medical cessation case, the AC also sends an SSI Payment Status Request to the servicing FO with a copy of the medical cessation remand. The AC will also send the hearing office (HO) a transmittal slip alerting the HO that the case is one in which the claimant and auxiliaries may elect to receive continued disability payments pending readjudication of the claim(s) for benefits by the ALJ. The AC will send transmittal slips for paper and electronic claim(s) files.

NOTE:

If the AC issues a remand combined with a partially favorable decision on the same claim and the claim(s) file is electronic, the claim must be converted to a paper file.

1. HO Issues Notice to Claimant on Remand

The HO is required to send a notice to the claimant in each individual case. The type of notice depends on whether the individual previously received continued payments and whether the individual is currently in payment status, as described in parts a, b, and c below. If it is not apparent from the file, or the HO cannot obtain this information independently, it can be obtained from the servicing field office (FO) through their use of Supplemental Security Income (SSI) queries. The FO staff will provide the information by telephone to the HO Director or other designated HO staff person, for efficiency, and then the FO will fax the SSI Payment Status Request form. If the HO does not receive a telephone call from the FO within ten days of receiving the remand order, the HO should telephone the FO as a reminder.

When the FO sends written confirmation to the HO in the form of the completed SSI Payment Status Request, the form must be attached to the claims file(s). For a paper claims file(s), the HO will staple the SSI Payment Status Request confirmation to the claim folder. For electronic claim(s) files, the HO should add the SSI Payment Status Request to the certified electronic folder (CEF).

NOTE:

In some court remand cases, the paper claim(s) file cannot be forwarded immediately to the HO with the remand order. In such cases, the HO should not wait to receive the claim(s) file. Instead, the HO should send the proper payment continuation notice to the individual, based upon the information received from the FO.

Based upon the information received from the FO, the HO will promptly send the appropriate notice to the individual (and representative payee, if any) to their last known address, as required by a, b, or c below. Copies of notices prepared by the HO should be sent to the individual's authorized representative, if any, and the servicing FO. A copy should also be placed in the paper file or uploaded to the CEF.

The HO should take the following actions indicated based on the circumstances that apply to the case:

a. Individual Previously Received Continued Payments at the ALJ Level, but Payments Were Terminated

When the HO receives the completed SSI Payment Status Request from the FO and Part 2, Item a is checked, then the HO will:

  • Send a notice (see Hearings, Appeals and Litigation Law (HALLEX) manual I-2-8-100) to the individual (and representative, if any). The notice will inform the individual that the FO will take necessary actions regarding eligibility and reinstatement of payments, and that he or she may also waive payment continuation by contacting the FO to complete a written waiver request for processing; and

  • Associate the waiver request received from the FO with the claim(s) file.

b. Individual Previously Received Continued Payments at the ALJ Level, and Payments Were Not Terminated

When the HO receives the completed SSI Payment Status Request from the FO and Part 2, Item b is checked, then the HO will:

  • Send a notice (see HALLEX I-2-8-101) to the individual (and representative, if any). The notice will inform the individual that payments will continue and that no further action is necessary to continue to receive payments unless the FO requests information for a redetermination, or the individual now wants to waive payment continuation by contacting the FO to complete a written waiver request, and

  • Associate the waiver request with the claim(s) file.

    NOTE:

    No action by the HO is necessary with regard to reinstatement of payments. Payments should continue (as long as the individual meets the nondisability requirements of eligibility), unless and until an unfavorable decision or a dismissal order is issued following the remand.

c. Individual Previously Did Not Receive Continued Payments at the ALJ Level, Payments Were Not Requested, or the Request Was Filed Late and Good Cause Was Not Established

When the HO receives the completed SSI Payment Status Request from the FO and Part 2, Item c is checked, then the HO will:

  • Send a notice (see HALLEX I-2-8-102) to the individual (and representative, if any). The notice will inform the individual that he or she may now request payment continuation by contacting the FO within 10 days of receiving the notice;

  • Send a copy of the notice to the servicing FO with a 505 Misc transmittal annotated as follows: “Possible Title XVI Payment Continuation Case. Individual did not previously receive continued payments. The case has now been remanded and the individual has been sent a notice directing him or her to contact any Social Security Office if he or she wants to request continued payments (copy attached);” and

  • Associate the request forwarded by the FO with the claim(s) file, if the individual contacts the FO to request payment continuation.

2. Individual (or Representative) Requests Benefit Continuation

Individuals (or representatives, if any) who believe that they are eligible for payment continuation may not wait to receive notices, but may contact HOs on their own. In such cases, the HO will:

  • Refer the individual to the servicing FO to record, in writing, the request for payment continuation;

  • Notify the servicing FO of the remand order, the date of the order, the individual's name and SSN, and the current status of the remand by telephone, with written confirmation by memorandum in the format of HALLEX I-2-8-103;

    NOTE 1:

    Check off item 1a or 1b to indicate whether it was the individual or the representative who initiated the request and fill in the date of the contact, and, if 1b is checked, the representative's name.

    NOTE 2:

    Check off item 2a or 2b to indicate whether there was a final action yet at the hearing level on the remanded case. If item 2a is checked, fill in the date of the ALJ decision or dismissal order and attach a copy. If item 2b is checked, fill in the date of the prior (vacated) decision or dismissal order, and the date of the current remand order.

  • Associate the individual's completed request for payment continuation received from the FO with the claim(s) file; and

  • Not send a notice regarding payment continuation to the individual(s) (or representative) who initiated the process.

Unless the HO indicates that a decision/dismissal order has already been issued (item 2.a. is checked off on HALLEX I-2-8-103), the FO will take necessary actions regarding redetermination and reinstatement of continued payments.

C. Notices - Title II-only Cases

When the AC remands a title II-only medical cessation case, the AC will send the HO a transmittal slip alerting the HO that the case is one in which the claimant and auxiliary beneficiaries may elect to receive continued disability payments pending readjudication of the claim(s) for benefits by the ALJ. The AC will send transmittal slips on paper and electronic claims files, and for electronic claim(s) files, the AC will input a remark in the Alerts and Messages section of the electronic folder, stating “Potential Continued Disability Payments Pending Readjudication.”

1. Individual Elected Continued Payments Pending ALJ Decision

If the Appeals Council remands the case, the HO will send a notice to the claimant (and representative, if any) and any auxiliary beneficiaries receiving benefits on the claimant's record, informing the individual(s) that payments will start again and that no further action by the individual is necessary to have the benefits reinstated. The notice will also tell the individual to report to the FO any changes or events that may affect the receipt of benefits. See HALLEX 1-2-8-105.

2. Individual Did Not Elect Continued Payments Pending ALJ Decision

If the Appeals Council remands the case and the claimant did not previously elect to have benefits continued pending an ALJ decision, the HO will:

  • Send a notice to the individual(s) (and representative, if any). The notice will inform the individual that he or she may now request payment continuation by contacting the FO within 10 days of receiving the notice;

  • Send a copy of the notice to the servicing FO. The Misc 505 transmittal (on DGS) should be annotated as follows: “Possible Title II Payment Continuation Case. Individual did not previously receive continued payments. The case has now been remanded and the individual has been sent a notice directing him or her to contact any Social Security Office if he or she wants to request continued payments (copy attached);” and

  • Associate the individual's completed request for payment continuation received from the FO with the claim(s) file.

D. ALJ Decision on Remand

1. Fully Favorable Decisions – Conversion of Payments

If the ALJ issues a fully favorable decision after the AC remand, the HO will:

  • Send the decision to the claimant (and representative, if any) and advise the claimant of the right to appeal the decision. See 20 CFR 404.967 and 416.1467;

  • Send, in both paper and electronic claims files, a paper copy of the favorable title XVI-only or concurrent (titles II and XVI) decision to the FO or a copy of the favorable title II-only decision to the processing center (PC), and annotate the Misc 505 transmittal as follows: “Fully favorable decision — please convert continued payments to regular, monthly payments;” and

  • Not send a termination memorandum, as described in D.2. below.

2. Partially Favorable or Unfavorable Decisions and Dismissals – Payment Termination

If the ALJ issues a partially favorable or unfavorable decision or an order of dismissal after an Appeals Council remand, the HO will:

  • Send the decision to the claimant (and representative, if any) and advise the claimant of the right to appeal the decision. See 20 CFR 404.967 and 416.1467; and

  • Initiate termination of continued payments;

    NOTE:

    In title XVI-only or concurrent cases,

  • If the notice in HALLEX I-2-8-100 (reinstatement of continued payments) or the notice in HALLEX I-2-8-101 (continuation of existing payments) was sent, the HO will initiate termination action unless a written waiver of continued payments by the recipient was received from the FO.

  • If the notice in HALLEX I-2-8-102 (offer of continued payments) was sent, the HO will initiate termination action if a written request for payment continuation by the individual was received from the FO, or if it is not known whether or not the individual requested continued payments.

  • Send, in both paper and electronic claims files, a paper copy of the decision or order of dismissal to the PC or FO with a memorandum formatted as shown in HALLEX I-2-8-104; and

  • Place a copy of the decision or order of dismissal and the memorandum in the claims file.

To minimize overpayments, every effort should be made to transmit the termination information to the servicing FO or PC as quickly as possible.

3. Recommended Decisions

In cases where the ALJ issues a recommended decision after the Appeals Council remand, the HO will:

  • Send the recommended decision to the claimant and representative, if any;

  • Not initiate termination action; and

  • Follow the instructions in HALLEX I-2-8-15.

E. Overpayments and Waiver of Recovery

Components outside of the Office of Disability Adjudication and Review are responsible for effectuating the termination of continued payments, computing the amount of any potential overpayment, notifying the recipient, and explaining the right to request waiver of recovery of the overpayment. If the HOs receive questions on these subjects, refer individuals to the servicing FO or PC.

ALJs have the authority under the regulations to consider new issues, in a case properly before them, that were not previously considered. See 20 CFR 404.946 and 416.1446. However, ALJs should not ordinarily consider new issues of overpayment and waiver of recovery if they have not previously been considered at earlier stages in the administrative process. See HALLEX I-2-2-10.