I-2-8-7.Statutory Benefit Continuation in Medical Cessation Cases Remanded by the Appeals Council

Last Update: 3/28/25 (Transmittal I-2-270)

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the administrative law judge's (ALJ) decision or dismissal order issued on a medical cessation appeal is vacated and is no longer in effect.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, may be payable pending a new decision by the ALJ or final action by the AC on the ALJ's recommended decision.

If an eligible claimant and/or their auxiliaries previously elected to receive continued benefits pending the ALJ's decision, the agency will automatically restart the benefits. If the claimant and their auxiliaries did not previously elect to have benefits continued pending the 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.

NOTE:

An individual is presumed to have received a notice five days after the date on the notice unless they can show us that they did not receive it within the five-day period (20 CFR 404.901 and 416.1401).

The agency must send statutory benefit continuation (SBC) notices to the claimant in all cases. See 20 CFR 404.1597a and 416.996. The agency must also send SBC notices to any auxiliaries in cases involving Title II. See 20 CFR 404.1597a.

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 alerts the servicing field office (FO) of the benefit continuation issue.

The AC will upload the remand order, transmittal sheet, and SSI Payment Status Request to eView (or the Electronic Non-Medical Folder (ENM) for paper cases). The transmittal sheet and SSI Payment Status Request are appended to the end of the remand order and will contain the following language, “Possible Title XVI Payment Continuation Case,” alerting the hearing office (HO) that the case is one in which the claimant and their auxiliaries may elect to receive continued disability payments pending readjudication of the claim(s) for benefits by the ALJ (see Hearings, Appeals and Litigation Law (HALLEX) manual I-3-7-40 C.1).

NOTE:

There are no auxiliary beneficiaries for Title XVI-only cases.

1. Hearing Office Issues Notice to Claimant and Auxiliaries on Remand

The HO is required to send a notice to the claimant and their auxiliaries in each case. The specific notice (see Standard Hearings Operations Procedure (SHOP) 1.4.3) depends on whether the claimant and their auxiliaries previously received continued payments and whether they are currently in payment status, as described in parts a, b, and c below.

This information is included in the completed SSI Payment Status Request form. The FO will gather this information, complete the form, and upload the form to eView (or ENM for paper cases) and notify the HO via email. If the HO does not receive an email from the FO within 10 days of receiving the remand order, the completed form is not in the file, and the HO cannot obtain this information independently, the HO may contact the servicing FO by sending an assistance request for electronic cases in eView (or an email to the servicing FO's email address for paper cases) requesting that the FO complete an SSI Payment Status Request form (See POMS DI 12095.172 Exhibit 1).

NOTE 1:

Use the Detailed Office/Organization Resource System (DOORS) to identify the servicing FO email address.

If the FO sends the completed SSI Payment Status Request form to the HO in any other manner, the HO will upload the form to eView (or ENM for paper cases).

NOTE 2:

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 claimant and their auxiliaries, based upon the information received from the FO.

Based upon the information received from the FO, the HO will promptly send the appropriate notice (see parts a, b, and c below) to the claimant and their auxiliaries (and representative payee, if any) to their last known address. The HO will also send a copy of the notice(s) to the authorized representative, if any. The HO will upload the notice(s) to eView (or ENM for paper cases).

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

a. Claimant and/or Auxiliaries Previously Elected 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 the appropriate notice (see SHOP 1.4.3) to the claimant and any auxiliaries (and representative, if any). The notice will inform the individual that the FO will take necessary actions regarding eligibility and reinstatement of payments. The notice will also inform the individual that they may also decline payment continuation by contacting the FO to complete a written waiver request for processing.

If the individual submits a waiver request to the HO, upload the request to eView (or ENM for paper cases) and alert the FO by sending an assistance request for electronic cases in eView (or an email to the servicing FO's email address for paper cases).

b. Claimant and/or Auxiliaries Previously Elected 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 the appropriate notice (see SHOP 1.4.3) to the claimant and any auxiliaries (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 decline payment continuation by contacting the FO to complete a written waiver request.

If the individual submits a waiver request to the HO, upload the request to eView (or ENM for paper cases) and alert the FO by sending an assistance request for electronic cases in eView (or an email to the servicing FO's email address for paper cases).

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. Claimant and/or Auxiliaries Previously Did Not Elect 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 the appropriate notice (see SHOP 1.4.3) to the claimant and any auxiliaries (and representative, if any). The notice will inform the individual that they may now request payment continuation by contacting the FO within 10 days of receiving the notice.

If the individual submits request for payment continuation to the HO, upload the request to eView (or ENM for paper cases) and alert the FO by sending an assistance request for electronic cases in eView (or an email to the servicing FO's email address for paper cases).

2. Claimant and/or Auxiliaries (or Representative) Requests Benefit Continuation

A claimant and/or auxiliary beneficiary (or appointed representative, if any) who believes that they are eligible for payment continuation may contact the HO on their own before receiving the notices. In such cases, the HO will:

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

  • Document the contact in a form SSA-5002, Report of Contact (ROC); and

  • Send an assistance request for electronic cases in eView (or an email to the servicing FO's email address for paper cases) with the information in 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.

If the individual submits a completed request for payment continuation to the HO, upload the request to eView (or ENM for paper cases). The HO will not send the 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 alert the HO that the claimant and auxiliary beneficiaries may elect to receive continued disability payments pending readjudication of the claim(s) for benefits by the ALJ pursuant to HALLEX I-3-7-40 C.2 and PANDA section A.5.2.2):

  • For paper cases, the AC will email a separate transmittal sheet to the HO indicating the case is a “Potential Benefit Continuation Case.”

  • For electronic claims files, the AC will add a remark in eView in the Alerts and Messages section stating, “Potential Continued Disability Payments Pending Readjudication.”

In Title II-only cases, the HO must notify the FO, in addition to the claimant and any auxiliary beneficiaries, of the remanded case.

1. Claimant and/or Auxiliaries Elected Continued Payments Pending ALJ Decision

a. HO Notice to the Claimant and/or Auxiliaries

If the AC remands the case and the claimant and/or their auxiliaries previously elected benefit continuation pending the prior ALJ decision, the HO will send the appropriate notice (see SHOP 1.4.3) to the claimant (and representative, if any) and any auxiliary beneficiaries receiving benefits on the claimant's record, informing them that payments will start again and that no further action 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 or if they now wish to decline benefit continuation.

b. HO Notice to the FO

The HO will also notify the FO of the remanded case and the benefit continuation issue through an assistance request for electronic cases in eView or an email to the servicing FO's email address for paper cases.

NOTE:

Use DOORS to identify the servicing FO email address.

The email message must include the claimant's Social Security number, name, the date of the vacated ALJ decision, and the following language:

“Title II Payment Continuation Case. The claimant and/or their auxiliaries previously elected to receive continued benefits pending the ALJ's decision. The AC has remanded the decision and SBC should be continued automatically.”

c. The Electronic Folder

The HO will ensure that the following are in eView (or ENM for paper cases):

  • The remand order; and

  • The notices to the claimant, any auxiliaries, and any appointed representative(s).

2. Claimant and/or Auxiliaries Did Not Elect Continued Payments Pending ALJ Decision

a. HO Notice to the Claimant and Auxiliaries

If the AC remands the case and the claimant and/or their auxiliaries did not previously elect to have benefits continued pending an ALJ decision, the HO will send a notice (See SHOP 1.4.3) to the claimant (and representative, if any) and any auxiliary beneficiaries eligible to receive benefits on the claimant's record, informing them that they may now request payment continuation by contacting the FO within 10 days of receiving the notice.

b. HO Notice to the FO

The HO will also notify the FO of the remanded case and the benefit continuation issue through an assistance request for electronic cases in eView or an email to the servicing FO's email address for paper cases.

NOTE:

Use DOORS to identify the servicing office email address.

The email message must include the claimant's Social Security Number, name, the date of the vacated ALJ decision, and the following language:

“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 them to contact the servicing Social Security office if they want to request continued payments.”

c. The Electronic Folder

The HO will ensure that the following are in eView (or ENM for paper cases):

  • The remand order; and

  • The notice(s) to the claimant, any auxiliaries, and any appointed representative(s).

D. ALJ Decision on Remand

If benefits were not continued following the AC remand, follow normal procedures outlined in HALLEX I-2-8-1 and SHOP 6.4.

NOTE:

Refer to the Supplemental Security Income Display (SSID) and Master Beneficiary Record (MBR) queries to determine if the claimant is in pay status at the time of the decision.

If benefits were continued, proceed as follows:

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;

  • Annotate the transmittal as follows:

    “Fully favorable decision — please convert continued payments to regular, monthly payments;”

  • Place a copy of the decision in eView (or ENM for paper cases); and

  • For paper cases, send a copy of the decision and transmittal via Desktop Fax to the effectuating component (see SHOP 6.4).

NOTE:

For electronic cases, the transmittal data is automatically added to the Case Data tab in eView.

2. Closed Period or Unfavorable Decisions and Dismissals – Payment Termination

If the ALJ issues a closed period or unfavorable decision or an order of dismissal after an 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;

  • Place a copy of the decision or order of dismissal in eView (or ENM for paper cases); and

  • Initiate termination of continued payments by adding the following to the transmittal:

  • In the transmittal remarks,

  • Check the box indicating the following:

    “Further action necessary by claims processing component.”

  • Annotate the transmittal as follows:

    "The individual in this medical cessation case appears to have had disability payments/benefits continued through the hearing level. The ALJ's decision/dismissal of   (date)   is unfavorable; disability ceased on   (date)  .

    Please terminate continued disability payments/benefits immediately."

  • For paper cases, send a copy of the decision or order of dismissal and the transmittal via Desktop Fax to the effectuating component (See SHOP 6.4).

NOTE:

For electronic cases, the transmittal data is automatically added to the Case Data tab in eView.

To minimize overpayments, every effort should be made to transmit the termination information to the effectuating component as quickly as possible.

3. Recommended Decisions

In cases where the ALJ issues a recommended decision after the AC 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 Hearings Operations 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 Program Service Center.

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.