EDPNA TERMS Flashcards
Disabled Widow(er) Benefits (DWB or DIWW) 404.335
The disability benefits are available to disabled widows and widowers of insured workers, with benefits first payable to the widow(er) at an age between age 50 and 60.
- Disability began w/in 7 years after the spouses death
- Deceased spouse must have been on T2 benefits or had T2 insured status before death
Substitution of Party POMS 23510.035
**Rule is NOT in CFR (hallex 1-2-1-50)
SSA - 539 Form
T16 - limited to surviving spouse who was living w/ claimant within the past 6 months or parent/parents of disabled or blind child.
Order of Sub for T2:
1. Surviving Spouse
2. Children entitled to monthly benefits
3. Parents of claimant who are entitled
4. Surviving Spouse (not living w/ claimant)
5. Children of claimant
6. Parents of claimant
7. Legal rep of estate
The Substitution of Party rule you’re referring to is part of the Program Operations Manual System (POMS), which is a reference manual for Social Security Administration (SSA) employees. Specifically, POMS DI 23510.035 deals with the procedure following the death of a claimant after filing for Title XVI benefits1.
Here’s a brief explanation of the rule:
Title XVI (SSI): If a claimant dies after filing but before a decision is made, and there is no surviving eligible spouse, the case is returned to the field office unadjudicated unless there are unpaid medical expenses or the state’s disability determination services (DDS) makes Medicaid eligibility determinations1.
Surviving Eligible Spouse: If there is a surviving eligible spouse, the DDS must make a disability determination. The SSA-831 form is completed with specific instructions for fully favorable allowance determinations1.
Order of Substitution for Title II (T2): The order you listed is for the substitution of parties for Title II benefits, which includes Social Security Disability Insurance (SSDI). The order prioritizes who can act on behalf of the deceased claimant, starting with the surviving spouse, children, parents, and finally, the legal representative of the estate.
The SSA-539 Form is likely related to the process of reporting a death to the SSA. The rule you mentioned is not found in the Code of Federal Regulations (CFR) but is instead detailed in the POMS, which provides operational guidance to SSA staff.
For more detailed information, you can refer to the POMS directly through the SSA website1. Please note that this explanation is based on the information available up to 2021, and for the most current procedures, you should consult the latest version of the POMS or contact the SSA directly.
Disabled Adult Children Benefits (DAC) 404.350
Disabled Adult Children (DAC) Benefits refer to Social Security benefits that are available to adult children who have a disability that began before they turned 22 years old. Here are the key points about DAC benefits:
Eligibility: To qualify, the individual must be the child of a retired, disabled, or deceased worker and have a disability that started before age .
Dependence: The adult child must be dependent on the parent’s Social Security earnings record.
Unmarried Status: The individual must be unmarried to receive DAC benefits.
Continuous Disability: There must be proof of continuous disability since before reaching age.
These benefits are designed to provide financial support to individuals who are unable to work due to a disability that began in childhood. DAC benefits are based on the parent’s earnings record, not the disabled adult child’s work history.
Special Insured Status 404.130
The Special Insured Status 404.130 refers to the rules for determining disability insured status for individuals who become disabled before the age of 31. Here’s a breakdown of the rule:
Fully Insured: The individual must be fully insured, which means they have earned the required number of quarters of coverage (QCs) based on their age and work history.
Quarters of Coverage (QCs): The individual must have QCs in at least one-half of the quarters during the period that ends with the quarter in question and begins with the quarter after they turned 21. The specifics are as follows:
If the number of quarters during this period is an odd number, the required number of QCs is reduced by one.
If the period has less than 12 quarters, the individual must have at least 6 QCs in the 12-quarter period ending with that quarter.
These rules ensure that younger workers who have not had the opportunity to work as long as older workers can still qualify for disability benefits if they meet the insured status requirements
Continuing Disability Reviews 404.1589 416.989
Continuing Disability Reviews (CDRs) are evaluations conducted by the Social Security Administration (SSA) to determine if individuals who are receiving disability benefits are still eligible due to their medical condition. The reviews are a standard part of the SSA’s process to ensure that only those who continue to meet the medical criteria for disability receive benefits.
For Title II benefits (Social Security Disability Insurance), the relevant regulation is 20 CFR 404.15891. It states that the SSA must periodically evaluate the impairment(s) of beneficiaries to determine ongoing eligibility for disability cash benefits. This is known as a CDR. The SSA may initiate a CDR for various reasons, including if there is an indication that the beneficiary’s medical condition has improved or if the beneficiary has not followed prescribed treatment.
Similarly, for Title XVI benefits (Supplemental Security Income), the corresponding regulation is 20 CFR 416.9892. This regulation also requires periodic reviews of beneficiaries’ impairments to determine if they continue to be eligible for payments based on disability.
During a CDR, the SSA will develop a complete medical history of at least the preceding 12 months to make a determination. If the review indicates that the beneficiary is no longer disabled, the SSA will provide written notice and an opportunity to appeal the decision.
For more detailed information, you can refer to the Electronic Code of Federal Regulations (eCFR) or contact the SSA directly.
Trial Work Period (TWP) 404.1592
The Trial Work Period (TWP) is a provision that allows individuals receiving Social Security Disability Insurance (SSDI) to test their ability to work for at least 9 months without affecting their benefits. Here are the key points of 20 CFR 404.1592 regarding TWP:
Definition: TWP is a period during which you may test your ability to work while still being considered disabled.
Duration: It consists of up to 9 months, which do not need to be consecutive1.
Earnings Threshold: In 2023, any month where earnings exceed $1,050 is considered a month of services for TWP. In 2024, this amount increases to $1,1102.
Services: Activities performed in employment or self-employment for pay or profit are considered services.
End of TWP: After the TWP has ended, the work done during the period is considered in determining whether your disability ended after the TWP.
The TWP is designed to encourage SSDI beneficiaries to attempt to return to work if they are able, without the immediate risk of losing their disability benefits. For more detailed information, you can refer to the Electronic Code of Federal Regulations (eCFR) or the Program Operations Manual System (POMS) provided by the SSA.
In-Kind Income
In-Kind Income refers to any income received in a form other than money. This can include goods or services provided for free or at a reduced cost. Here are some key points about in-kind income:
Types: It often includes free room and board, food, clothing, or other goods and services1.
SSI Impact: For individuals receiving Supplemental Security Income (SSI), in-kind income can affect the amount of their benefit payment. The Social Security Administration (SSA) considers free food and shelter as in-kind support and maintenance (ISM), which can reduce SSI payments1.
Non-Countable ISM: Certain types of support, such as cable, telephone, internet services, vehicle expenses, and medical expenses, are not considered ISM and do not affect SSI benefits1.
In-kind income is an important consideration for SSI eligibility and benefit calculations. For more detailed information, you can refer to the SSA’s guidelines or consult with a legal expert specializing in social security law.
Earned Income 416.1111
In the context of Social Security Disability, Earned Income as defined in 20 CFR 416.1111 refers to income received from wages, net earnings from self-employment, payments for services in sheltered workshops or activities centers, in-kind earned income, and royalties and honoraria. Here’s a brief overview:
Wages: Counted when received, credited to your account, or set aside for your use. Wages for uniformed service members are counted as received in the month they are earned1.
Net Earnings from Self-Employment: Counted on a taxable year basis and divided equally among the months in the taxable year1.
Payments for Services: Counted when received or set aside for your use, determined quarterly1.
In-Kind Earned Income: Valued at current market value for SSI purposes1.
Royalties and Honoraria: Counted when received, credited to your account, or set aside for your use1.
For a detailed explanation, you can refer to the eCFR (Electronic Code of Federal Regulations) website.
Unearned Income 416.1121 416.1124
Unearned Income in the context of Social Security Disability refers to income that is not earned from work or business activities. According to 20 CFR 416.1121 and 416.1124, unearned income includes:
Annuities, pensions, and other periodic payments: These are usually related to prior work or service, such as private pensions, social security benefits, disability benefits, veterans benefits, worker’s compensation, railroad retirement annuities, and unemployment insurance benefits.
Alimony and support payments: Cash or in-kind contributions to meet a person’s needs for food or shelter, which may be made voluntarily or due to a court order.
Dividends, interest, and certain royalties: Returns on capital investments like stocks, bonds, or savings accounts, and compensation paid to the owner for the use of property.
Rents: Payments received for the use of real or personal property, with certain deductible expenses.
Death benefits: Payments received occasioned by the death of another person, except for amounts spent on the deceased person’s last illness and burial expenses.
Additionally, 20 CFR 416.1124 outlines unearned income that is not counted for SSI purposes, such as:
Income excluded by other Federal laws: Certain types of unearned income are not counted due to provisions in other Federal laws.
Assistance based on need: Assistance wholly funded by a State or its political subdivisions, and used for determining eligibility based on income.
Educational grants and scholarships: Portions used for tuition, fees, or other necessary educational expenses are not counted.
Disaster relief: Assistance received under the Disaster Relief and Emergency Assistance Act or due to a major disaster declared by the President.
Infrequent or irregular unearned income: Up to $60 of unearned income received infrequently or irregularly in a calendar quarter.
For a comprehensive understanding, you can refer to the eCFR (Electronic Code of Federal Regulations) and SSA (Social Security Administration) websites.
One-Third Reduction Rule 416.1131
The One-Third Reduction Rule as outlined in 20 CFR 416.1131 is a guideline used by the Social Security Administration (SSA) to simplify the assessment of in-kind support and maintenance for individuals receiving Supplemental Security Income (SSI). Here’s a concise explanation:
Rule Application: If an individual (or an individual and their eligible spouse) lives in another person’s household for a full calendar month (except for temporary absences) and receives both food and shelter from that person, the SSA counts one-third of the Federal benefit rate as additional income.
Full or None: The one-third reduction applies in full or not at all. No income exclusions are applied to the reduction amount, but appropriate exclusions are applied to any other earned or unearned income.
Other Support: If the one-third reduction rule applies, the SSA does not count any other in-kind support and maintenance received.
This rule is designed to streamline the process of determining SSI eligibility and benefit amounts by providing a standard deduction instead of calculating the actual dollar value of the support provided. For further details, you can review the information provided by the SSA.
Presumed Maximum Value (PMV) 416.1140
The Presumed Maximum Value (PMV), as outlined in 20 CFR 416.1140, is a guideline used by the Social Security Administration (SSA) to estimate the value of in-kind support and maintenance (ISM) when the one-third reduction rule does not apply. Here’s a brief explanation:
PMV Application: When you receive ISM and the one-third reduction rule does not apply, the SSA uses the PMV rule. Instead of determining the actual dollar value of any food or shelter you receive, the SSA presumes it is worth a maximum value.
Maximum Value: This maximum value is one-third of your Federal benefit rate plus the amount of the general income exclusion described in § 416.1124©(12)1.
Rebuttal of PMV: You can show that the current market value of the ISM you receive, minus any payment you make for it, is lower than the PMV. If you do, the SSA will use the actual value instead of the PMV to figure your unearned income.
For a detailed understanding, you can refer to the official SSA website or the eCFR
Income Deeming 416.1160
Income Deeming as described in 20 CFR 416.1160 refers to the process where the Social Security Administration (SSA) considers another person’s income as if it were your own for the purpose of determining Supplemental Security Income (SSI) eligibility and benefit amounts. Here’s a summary:
General Concept: Deeming is the assumption that part of another person’s income is available to you, affecting your SSI eligibility and payment amount.
Applicable Situations: Income can be deemed from an ineligible spouse, parent, sponsor of an alien, or an essential person.
Purpose: The rationale behind deeming is the expectation that these individuals contribute to your support.
Impact on Benefits: Deeming can affect both the eligibility for SSI benefits and the calculation of the benefit amount.
For a detailed explanation, you can refer to the official SSA website.
Resources 416 Subpart L (SSI only)
Subpart L of 20 CFR Part 416 outlines the regulations regarding resources for Supplemental Security Income (SSI) eligibility. Here’s a summary:
Resources Defined: Resources are cash, liquid assets, or any real or personal property that an individual or their spouse owns and could convert to cash for support and maintenance.
Exclusions: Certain resources are not counted towards SSI eligibility, such as the home, household goods, personal effects, and one automobile.
Limits: There are limitations on the amount of resources an individual or couple can have to remain eligible for SSI.
Deeming: Some resources of a spouse, parent, or sponsor of an alien may be deemed as belonging to the individual applying for SSI.
For a comprehensive understanding, you can refer to the eCFR which provides detailed information on these regulations.
Res Judicata 404.957 416.1457
Res Judicata is a legal doctrine that prevents an issue from being re-litigated once it has been judged on its merits and a final decision has been rendered. In the context of Social Security Administration (SSA) hearings, as per 20 CFR 404.957 and 416.1457, an Administrative Law Judge (ALJ) may dismiss a request for a hearing if the doctrine of res judicata applies. This can occur when:
There has been a previous determination or decision about the individual’s rights on the same facts and issues.
The previous determination or decision has become final by either administrative or judicial action.
The ALJ may also dismiss a hearing request if the individual fails to appear at the hearing without good cause, or if the individual requesting the hearing has no right to it under the regulations. If a case is dismissed based on res judicata, it means that the matter has been conclusively decided and cannot be brought up again in a new hearing. This ensures the finality of decisions and prevents the re-litigation of issues that have already been settled.
Collateral Estoppel 404.950 416.1450
Collateral Estoppel, as per 20 CFR 404.950(f) and 416.1450(f), is a legal principle that prevents the re-litigation of an issue that has already been decided in a previous determination or decision involving the same parties but under a different title of the Social Security Act or the Federal Coal Mine Health and Safety Act. Here’s a brief explanation:
When It Applies: If an issue at your hearing is a fact that has been decided in a previous determination or decision, the Administrative Law Judge (ALJ) will not consider the issue again.
Binding Effect: The ALJ will apply collateral estoppel and accept the factual finding made in the previous determination or decision, unless there are reasons to believe it was wrong.
Difference from Res Judicata: Collateral estoppel differs from res judicata in that it applies to final determinations or decisions made under a different title about the individual’s rights on the same facts and issues. Res judicata is a basis for dismissal of a hearing request in its entirety or as to one or more issues, whereas collateral estoppel is not a basis for dismissal.
Common Law Marriage 404.726
Common Law
Marriage, as defined in 20 CFR 404.726, is a marriage that is considered valid under certain state laws even though there was no formal ceremony. It requires two persons who are free to marry, consider themselves married, live together as husband and wife, and meet other requirements specific to some states. Here’s a summary of the evidence required to establish a common-law marriage:
Preferred Evidence:
If both partners are alive: Signed statements from both and two blood relatives.
If one partner is deceased: Signed statement from the surviving partner and two blood relatives of the deceased.
If both partners are deceased: Signed statements from one blood relative of each.
Other Evidence:
If preferred evidence is unavailable, other convincing evidence of the marriage is required.
Statements should explain why the signer believes there was a marriage between the two persons.
For more details, you can refer to the eCFR website.
Self Employment 404.1575 416.975
The regulations for self-employment as described in 20 CFR 404.1575 and 416.975 provide guidance on how the Social Security Administration (SSA) evaluates work activity for individuals who are self-employed and applying for disability benefits or Supplemental Security Income (SSI). Here’s a summary of the key points:
Substantial Gainful Activity (SGA): The SSA uses specific criteria to determine if the work activity of a self-employed person qualifies as SGA, which is work that is both substantial and gainful.
Three Tests for SGA:
Test One: Evaluates if the services provided are significant to the operation of the business and if the individual receives a substantial income from the business.
Test Two: Compares the work activity to that of unimpaired individuals in the same or similar businesses in the community.
Test Three: Assesses if the work activity is clearly worth a certain amount when considered in terms of its value to the business or compared to what an owner would pay an employee to do the work.
Significant Services and Substantial Income: The regulations define what constitutes significant services and substantial income for the purposes of Test One.
Unsuccessful Work Attempts: Work activity that is stopped or reduced to below SGA level within six months due to an impairment may be considered an unsuccessful work attempt.
For a detailed understanding of how these guidelines apply to self-employment and disability benefits, you can refer to the eCFR and SSA websites.
Unsuccessful Work Attempt (UWA) 404.1592c
An Unsuccessful Work Attempt (UWA) is an effort to do substantial work in employment or self-employment which is discontinued or reduced to below the Substantial Gainful Activity (SGA) level after a short time (no more than 6 months) because of the individual’s impairment or the removal of special conditions related to the impairment that are essential to the further performance of work. Here’s a concise explanation:
Definition: A UWA is an attempt to work that does not last due to the individual’s disability or the removal of special conditions that accommodate the disability.
Duration: The work attempt must be less than 6 months to be considered unsuccessful.
Impact on Disability Benefits: Work performed during a UWA does not prevent a finding of disability and can be disregarded when evaluating eligibility for benefits.
For more detailed information, you can refer to the SSA’s Program Operations Manual System (POMS)1. If you have further questions or need clarification, feel free to ask!
Impairment-Related Work Expenses (IRWE)
Impairment-Related Work Expenses (IRWE) are costs for items or services that a person with a disability needs in order to work. The Social Security Administration (SSA) allows these costs to be deducted from earnings when determining eligibility for disability benefits or when calculating the countable income for Supplemental Security Income (SSI). Here’s a brief overview:
Eligibility: To qualify as IRWE, the expenses must be related to a physical or mental impairment and necessary for the individual to work.
Deductible Costs: These can include attendant care services, medical devices, equipment, prostheses, and similar items and services.
Non-Deductible Costs: Routine medical services, health and life insurance premiums, and similar expenses are not considered IRWE.
Payment: The individual must pay for the expenses themselves without reimbursement from other sources like Medicare, Medicaid, or private insurance.
Reasonable Limits: The amount of IRWE that may be deducted is subject to reasonable limits, and the cost must represent the standard charge for the item or service in the community.
For example, if an individual requires special transportation services to commute to work because of their disability, the cost of this service can be considered an IRWE and deducted from their countable income when determining their SSI cash payment.
For more detailed information, you can refer to the SSA’s Program Operations Manual System (POMS)
Plan to Achieve Self Support (PASS)
The Plan to Achieve Self-Support (PASS) is a program offered by the Social Security Administration (SSA) to help individuals with disabilities return to work. Here’s a summary of how PASS works:
Purpose: PASS allows individuals receiving SSI, or who could qualify for SSI, to set aside income and resources to pay for items or services needed to achieve a specific work goal.
Goal: The objective is to help disabled individuals find employment that reduces or eliminates their need for SSI or SSDI benefits.
Eligibility: To be eligible for a PASS, you must have a disability that makes it difficult for you to work, and you must need the items or services to reach a work goal.
Setting Up a PASS: You decide on a work goal and determine the necessary items and services. You can get help from various sources, including vocational rehabilitation counselors, organizations that help people with disabilities, or your local SSA office1.
Application: You submit a PASS application (SSA-545-BK) to the SSA for approval. If your goal is self-employment, you must also submit a business plan.
Review Process: A PASS expert reviews the plan to ensure the work goal is reasonable and that the items and services listed are necessary and reasonably priced
Good Cause for Reopening 404.988 416.1488
“Good Cause for Reopening” as outlined in 20 CFR 404.988 and 416.1488 refers to the conditions under which a determination, revised determination, decision, or revised decision may be reopened by the Social Security Administration (SSA). Here’s a summary of the conditions:
Within 12 Months: A case may be reopened for any reason within 12 months of the notice of the initial determination12.
Within Four Years (Title II) / Two Years (Title XVI): A case may be reopened within four years under Title II or two years under Title XVI if there is good cause, as defined in § 404.989 and § 416.1489 respectively.
At Any Time: A case may be reopened at any time if:
It was obtained by fraud or similar fault.
There are changes in the earnings record that affect the decision.
A person previously determined to be dead is found to be alive.
Clerical error or an error on the face of the evidence is discovered.
For a detailed understanding of what constitutes “good cause” and the specific provisions under each condition, you can refer to the eCFR and SSA websites.
Disability
the inability to do any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.
- To meet this definition, you must have a severe impairment(s) that makes you unable to do your past relevant work or any other substantial gainful work that exists in the national economy.
- If your severe impairment(s) does not meet or medically equal a listing in appendix 1, we will assess your residual functional capacity. We will use this RFC assessment to determine if you can do your past relevant work.
- If we find that you cannot do your past relevant work, we will use the same RFC assessment and your vocational factors of age, education, and work experience to determine if you can do other work.
Residual Functional Capacity Assessment (RFC) 404.1506
The Residual Functional Capacity (RFC) assessment is a comprehensive evaluation used by the Social Security Administration (SSA) to determine what an individual can still do despite their physical or mental limitations. As per 20 CFR 404.1506, the RFC assessment considers all relevant evidence in the case record to assess an individual’s ability to perform work-related activities on a regular and continuing basis.
Here’s a summary of the key points:
Purpose: The RFC assessment is used in the disability determination process to evaluate the extent of an individual’s impairment and their ability to perform work activities.
Considerations: The assessment takes into account the individual’s ability to perform physical activities such as sitting, standing, walking, lifting, carrying, pushing, and pulling, as well as mental activities like understanding, remembering, and applying information.
Use in Evaluation: The RFC is used at steps four and five of the SSA’s five-step sequential evaluation process for determining disability. It helps to decide if an individual can do any past relevant work or adjust to other work that exists in significant numbers in the national economy.
