I-3-1-16.OAO Branch Screening for Benefit Termination in Medical Cessation Cases
Last Update: 7/23/15 (Transmittal I-3-120)
When the Disability Determination Services determine that an individual is no longer disabled in a medical cessation case, the claimant or another party may elect to have benefits continue through the date of an administrative law judge (ALJ) decision. See 20 CFR 404.1597a and 416.996. If the continued benefits are elected and, on appeal, the ALJ subsequently issues an unfavorable decision or dismisses the request for hearing, benefits must be terminated.
B. Termination of Benefits in Medical Cessation Cases
The hearing office (HO) is responsible for alerting the effectuating component of the need for benefit termination in medical cessation cases where the ALJ subsequently issues an unfavorable decision or dismisses the request for hearing. Most benefits are terminated automatically at the hearing level, but some benefit terminations require manual action by the HOs. See Hearings, Appeals and Litigation Law (HALLEX) manual I-2-8-6.
Occasionally, the Appeals Council (AC) will receive a request for review that contains an unfavorable ALJ decision or a denial in a medical cessation case where continued benefit payments were not ceased. If this occurs, for paper and electronic claim file(s), the AC will request termination of benefits by accessing the Document Generation System (DGS), clicking on “MISC,” then “Misc 505 Transmittal,” and noting on the form that this is a “Medical Cessation Alert” case. If the case has an electronic claim(s) file, send the Misc 505 Transmittal and a copy of the unfavorable decision to the appropriate effectuating component. If the case has a paper claim(s) file, send the Misc 505 transmittal with a notation to contact the AC for any necessary documents from the case.