The expedited reinstatement provision provides you another option for regaining eligibility for benefits when we previously terminated your eligibility for disability benefits due to your work activity. The expedited reinstatement provision provides you the option of requesting that your prior eligibility for disability benefits be reinstated, rather than filing a new application for a new period of eligibility. Since January 1, 2001, you can request to be reinstated to benefits if you stop doing substantial gainful activity within 60 months of your prior termination. You must not be able to do substantial gainful activity because of your medical condition. Your current impairment must be the same as or related to your prior impairment and you must be disabled. To determine if you are disabled, we will use our medical improvement review standard that we use in our continuing disability review process. The advantage of using the medical improvement review standard is that we will generally find that you are disabled unless your impairment has improved so that you are able to work or unless an exception under the medical improvement review standard process applies. We explain the rules for expedited reinstatement in Secs. 416.999a through 416.999d. [70 FR 57144, Sept. 30, 2005] Sec. 416.999a Who is eligible for expedited reinstatement?
(a) You can have your eligibility to benefits reinstated under expedited reinstatement if--
(1) You were previously eligible for a benefit based on disability or blindness as explained in Sec. 416.202;
(2) Your disability or blindness eligibility referred to in paragraph (a)(1) of this section was terminated because of earned income or a combination of earned and unearned income;
(3) You file your request for reinstatement timely under Sec. 416.999b; and
(4) In the month you file your request for reinstatement--
(i) You are not able to do substantial gainful activity because of your medical condition, as determined under paragraph (c) of this section,
(ii) Your current impairment is the same as or related to the impairment that we used as the basis for your previous eligibility referred to in paragraph (a)(2) of this section,
(iii) You are disabled or blind, as determined under the medical improvement review standard in Secs. 416.994 or 416.994a, and
(iv) You meet the non-medical requirements for eligibility as explained in Sec. 416.202.
(b) You are eligible for reinstatement if you are the spouse of an individual who can be reinstated under Sec. 416.999a if--
(1) You were previously an eligible spouse of the individual;
(2) You meet the requirements for eligibility as explained in Sec. 416.202 except the requirement that you must file an application; and
(3) You request reinstatement.
(c) We will determine that you are not able to do substantial gainful activity because of your medical condition, under paragraph (a)(4)(i) of this section, when:
(1) You certify under Sec. 416.999b(e) that you are unable to do substantial gainful activity because of your medical condition;
(2) You do not do substantial gainful activity in the month you file your request for reinstatement; and
(3) We determine that you are disabled under paragraph (a)(4)(iii) of this section. [70 FR 57144, Sept. 30, 2005] Sec. 416.999b How do I request reinstatement?
(a) You must make your request for reinstatement in writing.
(b) You must have filed your request on or after January 1, 2001.
(c) You must provide the information we request so that we can determine whether you meet the eligibility requirements listed in Sec. 416.999a.
(d) We must receive your request within the consecutive 60-month period that begins with the month in which your eligibility terminated due to earned income, or a combination of earned and unearned income. If we receive your request after the 60-month period, we can grant you an extension if we determine you had good cause, under the standards explained in Sec. 416.1411, for not filing the request timely.
(e) You must certify that you are disabled, that your current impairment(s) is the same as or related to the impairment(s) that we used as the basis for the eligibility you are requesting to be reinstated, that you are unable to do substantial gainful activity because of your medical condition, and that you meet the non-medical requirements for eligibility for benefits. [70 FR 57144, Sept. 30, 2005] Sec. 416.999c How do we determine provisional benefits?
(a) You may receive up to six consecutive months of provisional cash benefits and Medicaid during the provisional benefit period, while we determine whether we can reinstate your disability benefit eligibility under Sec. 416.999a--
(1) We will pay you provisional benefits beginning with the month after you file your request for reinstatement under Sec. 416.999a(a).
(2) If you are an eligible spouse, you can receive provisional benefits with the month your spouse's provisional benefits begin.
(3) If you do not have an eligible spouse, we will pay you a monthly provisional benefit amount equal to the monthly amount that would be payable to an eligible individual under Secs. 416.401 through 416.435 with the same kind and amount of income as you have.
(4) If you have an eligible spouse, we will pay you and your spouse a monthly provisional benefit amount equal to the monthly amount that would be payable to an eligible individual and eligible spouse under Sec. 416.401 through 416.435 with the same kind and amount of income as you and your spouse have.
(5) Your provisional benefits will not include state supplementary payments payable under Secs. 416.2001 through 416.2176.
(b) You cannot receive provisional cash benefits or Medicaid a second time under this section when--
(1) You request reinstatement under Sec. 416.999a;
(2) You previously received provisional cash benefits or Medicaid under this section based upon a prior request for reinstatement filed under Sec. 416.999a(a); and
(3) Your requests under paragraphs (b)(1) and (b)(2) are for the same previous disability eligibility referred to in Sec. 416.999a(a)(2) of this section.
(4) Examples:
Example 1: Mr. K files a request for reinstatement in April 2004. His disability benefit had previously terminated in January 2003. Since Mr. K meets the other factors for possible reinstatement (i.e., his prior eligibility was terminated within the last 60 months because of his work activity) we start paying him provisional benefits beginning May 2004 while we determine whether he is disabled and whether his current impairment(s) is the same as or related to the impairment(s) that we used as the basis for the benefit that was terminated in January 2003. In July 2004 we determine that Mr. K cannot be reinstated because he is not disabled under the medical improvement review standard; therefore we stop his provisional benefits. Mr. K does not request review of the determination. In January 2005 Mr. K again requests reinstatement on the eligibility that terminated in January 2003. Since this request again meets all the other factors for possible reinstatement mentioned above, and his request is still within 60 months from January 2003, we will make a new determination on whether he is disabled and whether his current impairment(s) is the same as or related to the impairment(s) that we used as the basis for the benefit that was terminated in January 2003. Since the January 2005 request and the April 2004 request both request reinstatement on the same benefit that terminated in January 2003, and since we already paid Mr. K provisional benefits based upon the April 2004 request, we will not pay additional provisional benefits on the January 2005 request for reinstatement.
Example 2: Assume the same facts as shown in Example 1 of this section, with the addition of these facts. We approve Mr. K's January 2005 request for reinstatement and start his reinstated benefits beginning February 2005. Mr. K subsequently returns to work and his benefits are again terminated due to his work activity in January 2008. Mr. K again stops work and requests reinstatement in January 2010. Since Mr. K meets the other factors for possible reinstatement (i.e., his prior eligibility was terminated within the last 60 months because of his work activity) we start paying him provisional benefits beginning February 2010 while we determine whether he is disabled and whether his current impairment(s) is the same as or related to the impairment(s) that we used as the basis for the benefit that was terminated in January 2008.
(c) We will not pay you a provisional benefit for a month where you are not eligible for a payment under Secs. 416.1322, 416.1323, 416.1325, 416.1327, 416.1329, 416.1330, 416.1334, and 416.1339.
(d) We will not pay you a provisional benefit for any month that is after the earliest of either: the month we send you notice of our determination on your request for reinstatement; or, the sixth month following the month you requested expedited reinstatement.
(e) You are not eligible for provisional benefits if--
(1) Prior to starting your provisional benefits we determine that you do not meet the requirements for reinstatement under Secs. 416.999a(a); or
(2) We determine that your statements on your request for reinstatement, made under Sec. 416.999b(d)(2), are false.
(f) Determinations we make regarding your provisional benefits under paragraphs (a) through (e) of this section are final and are not subject to administrative and judicial review under subpart N of part 416.
(g) If you were previously overpaid benefits under title II or title XVI of the Act, we will not recover the overpayment from your provisional benefits unless you give us permission.
(h) If we determine you are not eligible to receive reinstated benefits, provisional benefits we have already paid you under this section that were made prior to the termination month under paragraph (d) of this section will not be subject to recovery as an overpayment unless we determine that you knew, or should have known, you did not meet the requirements for reinstatement in Sec. 416.999a. If we inadvertently pay you provisional benefits when you are not entitled to them because we have already made a determination described in paragraph (e) of this section, they will be subject to recover as an overpayment under subpart E of part 416. [70 FR 57144, Sept. 30, 2005] Sec. 416.999d How do we determine reinstated benefits?
(a) If you meet the requirements for reinstatement under Sec. 416.999a(a), we will reinstate your benefits with the month after the month you filed your request for reinstatement. We cannot reinstate your eligibility for any month prior to February 2001.
(b) We will compute your reinstated benefit amount and determine benefits payable under the applicable paragraphs in Secs. 416.401 through 416.435. We will reduce your reinstated benefit due in a month by a provisional benefit we already paid you for that month. If your provisional benefit paid for a month equals or exceeds the reinstated benefit due, we will treat the difference as an overpayment under Sec. 416.536.
(c) Once you have been reinstated under Sec. 416.999a you cannot be reinstated again until you have completed a 24-month initial reinstatement period. Your initial reinstatement period begins with the month your reinstated benefits begin under paragraph (a) of this section and ends when you have had 24 payable months of reinstated benefits. We consider you to have a payable month for the purposes of this paragraph when you are due a cash benefit of any amount for the month based upon our normal computation and payment rules in Sec. 416.401 through Sec. 416.435 or if you are considered to be receiving SSI benefits in a month under section 1619(b) of the Social Security Act. If your entire benefit payment due you for a month is adjusted for recovery of an overpayment under Secs. 416.570 and 416.571 or if the amount of the provisional benefit already paid you for a month exceeds the amount of the reinstated benefit payable for that month so that no additional payment is due, we will consider the month a payable month.
(d) Your eligibility for reinstated benefits ends with the month preceding the earliest of the following months--
(1) The month an applicable terminating event in Secs. 416.1331 through 416.1339 occurs;
(2) The third month following the month in which your disability ceases; or
(3) The month in which you die.
(e) Determinations we make under this section are initial determinations under Sec. 416.1402 and are subject to review under subpart N of part 416.
(f) If we determine you are not eligible for reinstated benefits, we will consider your request filed under Sec. 416.999a(a) your intent to claim benefits under Sec. 416.340. [70 FR 57144, Sept. 30, 2005]