I-2-8-6.Benefit Termination in Medical Cessation Cases

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

A. General

When the Disability Determination Services determines that an individual is no longer disabled in a medical cessation case, the claimant or another party may file a request for reconsideration or hearing before an administrative law judge (ALJ) and complete a written request electing that benefits continue through the date of the ALJ decision. The request must be made no later than 10 days after the date the claimant receives the notice that he or she is not disabled. See 20 CFR 404.1597a and 416.996.

NOTE:

In title II cases, the claimant may also elect to have benefits continue for anyone else who is receiving benefits based on the claimant's wages or self-employment income (auxiliary). In addition, the auxiliary will have to elect separately whether to have benefits continue pending the claimant's appeal.

If continued benefits are elected and, on appeal, the ALJ subsequently issues an unfavorable decision or dismisses the request for hearing, benefits must be terminated, regardless of whether the claimant or another party timely files a request for review with the Appeals Council.

B. Automatic Termination of Benefits

At the hearing level, when the following variables in the Case Processing and Management System (CPMS) are met, benefits will automatically terminate:

  • Claim type = DIWC, DIWW, DAC, SSID, or SSDC

  • Beneficiary Identification Code = A, C, W1-W9, WB, WF, WG, WJ, WR, and WT

  • Disposition: unfavorable (UAFF), or dismissal (ABDI, DXDI, IPDI, WDDI, or UTDI)

  • Hearing type indicates benefit continuation is involved, and

  • Case is coded as a medical cessation.

No additional action is required by hearing office (HO) staff.

C. Manual Termination of Benefits

When the variables in subsection B are not met, termination will not be automatic and will require HO staff to take action to request termination of benefits/payments.

For paper and electronic claim file(s), the HO may request termination of benefits by accessing the Document Generation System (DGS), clicking on “Correspondence,” “Post-Hearing,” and then “Medical Cessation Alert.” The Medical Cessation Alert must be appended to a copy of the unfavorable decision. If the case has an electronic claim(s) file, send the Medical Cessation Alert and a copy of the unfavorable decision to the appropriate effectuating component. If the case has a paper claim(s) file, send the Medical Cessation Alert and the file to the appropriate effectuating component.