[Code of Federal Regulations]
[Title 20, Volume 2]
[Revised as of January 1, 2007]
From the U.S. Government Printing Office via GPO Access
[CITE: 20CFR416]
[Page 817-1178]
TITLE 20--EMPLOYEES' BENEFITS
CHAPTER III--SOCIAL SECURITY ADMINISTRATION
PART 416_SUPPLEMENTAL SECURITY INCOME FOR THE AGED, BLIND, AND DISABLED--
Table of Contents
Subpart A_Introduction, General Provisions and Definitions
Sec.
416.101 Introduction.
416.105 Administration.
416.110 Purpose of program.
416.120 General definitions and use of terms.
416.121 Receipt of aid or assistance for December 1973 under an approved
State plan under title I, X, XIV, or XVI of the Social
Security Act.
Subpart B_Eligibility
General
416.200 Introduction.
416.201 General definitions and terms used in this subpart.
416.202 Who may get SSI benefits.
416.203 Initial determinations of SSI eligibility.
416.204 Redeterminations of SSI eligibility.
Reasons Why You May Not Get SSI Benefits for Which You Are Otherwise
Eligible
416.207 You do not give us permission to contact financial institutions.
416.210 You do not apply for other benefits.
416.211 You are a resident of a public institution.
416.212 Continuation of full benefits in certain cases of medical
confinement.
416.214 You are disabled and drug addiction or alcoholism is a
contributing factor material to the determination of
disability.
416.215 You leave the United States.
416.216 You are a child of armed forces personnel living overseas.
Eligibility for Increased Benefits Because of Essential Persons
416.220 General.
416.221 Who is a qualified individual.
416.222 Who is an essential person.
416.223 What happens if you are a qualified individual.
[[Page 818]]
416.250 Experimental, pilot, and demonstration projects in the SSI
program.
Special Provisions for People Who Work Despite a Disabling Impairment
416.260 General.
416.261 What are special SSI cash benefits and when are they payable.
416.262 Eligibility requirements for special SSI cash benefits.
416.263 No additional application needed.
416.264 When does the special SSI eligibility status apply.
416.265 Requirements for the special SSI eligibility status.
416.266 Continuation of SSI status for Medicaid.
416.267 General.
416.268 What is done to determine if you must have Medicaid in order to
work.
416.269 What is done to determine whether your earnings are too low to
provide comparable benefits and services you would receive in
the absence of those earnings.
Subpart C_Filing of Applications
General Provisions
416.301 Introduction.
416.302 Definitions.
416.305 You must file an application to receive supplemental security
income benefits.
Applications
416.310 What makes an application a claim for benefits.
416.315 Who may sign an application.
416.320 Evidence of authority to sign an application for another.
416.325 When an application is considered filed.
416.327 Pilot program for photographic identification of disability
benefit applicants in designated geographic areas.
Effective Filing Period of Application
416.330 Filing before the first month you meet the requirements for
eligibility.
416.335 Filing in or after the month you meet the requirements for
eligibility.
Filing Date Based Upon a Written Statement or Oral Inquiry
416.340 Use of date of written statement as application filing date.
416.345 Use of date of oral inquiry as application filing date.
416.350 Treating a title II application as an oral inquiry about SSI
benefits.
Deemed Filing Date Based on Misinformation
416.351 Deemed filing date in a case of misinformation.
Withdrawal of Application
416.355 Withdrawal of an application.
416.360 Cancellation of a request to withdraw.
Subpart D_Amount of Benefits
416.401 Scope of subpart.
416.405 Cost-of-living adjustments in benefits.
416.410 Amount of benefits; eligible individual.
416.412 Amount of benefits; eligible couple.
416.413 Amount of benefits; qualified individual.
416.414 Amount of benefits; eligible individual or eligible couple in a
medical care facility.
416.415 Amount of benefits; eligible individual is disabled child under
age 18.
416.420 Determination of benefits; general.
416.421 Determination of benefits; computation of prorated benefits.
416.426 Change in status involving an individual; ineligibility occurs.
416.428 Eligible individual without an eligible spouse has an essential
person in his home.
416.430 Eligible individual with eligible spouse; essential person(s)
present.
416.432 Change in status involving a couple; eligibility continues.
416.435 Change in status involving a couple; ineligibility occurs.
Subpart E_Payment of Benefits, Overpayments, and Underpayments
416.501 Payment of benefits: General.
416.502 Manner of payment.
416.503 Minimum monthly benefit amount.
416.520 Emergency advance payments.
416.525 Reimbursement to States for interim assistance payments.
416.532 Method of payment when the essential person resides with more
than one eligible person.
416.533 Transfer or assignment of benefits.
416.535 Underpayments and overpayments.
416.536 Underpayments--defined.
416.537 Overpayments--defined.
416.538 Amount of underpayment or overpayment.
416.542 Underpayments--to whom underpaid amount is payable.
416.543 Underpayments--applied to reduce overpayments.
416.544 Paying benefits in installments: Drug addiction or alcoholism.
416.545 Paying large past-due benefits in installments.
[[Page 819]]
416.546 Payment into dedicated accounts of past-due benefits for
eligible individuals under age 18 who have a representative
payee.
416.550 Waiver of adjustment or recovery--when applicable.
416.551 Waiver of adjustment or recovery--effect of.
416.552 Waiver of adjustment or recovery--without fault.
416.553 Waiver of adjustment or recovery--defeat the purpose of the
supplemental security income program.
416.554 Waiver of adjustment or recovery--against equity and good
conscience.
416.555 Waiver of adjustment or recovery--impede administration.
416.556 Waiver of adjustment or recovery--countable resources in excess
of the limits prescribed in Sec.416.1205 by $50 or less.
416.558 Notice relating to overpayments and underpayments.
416.560 Recovery--refund.
416.570 Adjustment--general rule.
416.571 10-percent limitation of recoupment rate--overpayment.
416.572 Are title II and title VIII benefits subject to adjustment to
recover title XVI overpayments?
416.573 How much will we withhold from your title II and title VIII
benefits to recover a title XVI overpayment?
416.574 Will you receive notice of our intention to apply cross-program
recovery?
416.575 When will we begin cross-program recovery from your current
monthly benefits?
416.580 Referral of overpayments to the Department of the Treasury for
tax refund offset--General.
416.581 Notice to overpaid individual.
416.582 Review within SSA that an overpayment is past due and legally
enforceable.
416.583 Findings by SSA.
416.584 Review of our records related to the overpayment.
416.585 Suspension of offset.
416.586 Tax refund insufficient to cover amount of overpayment.
416.590 Are there additional methods for recovery of title XVI benefit
overpayments?
Subpart F_Representative Payment
416.601 Introduction.
416.610 When payment will be made to a representative payee.
416.611 What happens to your monthly benefits while we are finding a
suitable representative payee for you?
416.615 Information considered in determining whether to make
representative payment.
416.620 Information considered in selecting a representative payee.
416.621 What is our order of preference in selecting a representative
payee for you?
416.622 Who may not serve as a representative payee?
416.624 How do we investigate a representative payee applicant?
416.625 What information must a representative payee report to us?
416.630 How will we notify you when we decide you need a representative
payee?
416.635 What are the responsibilities of your representative payee?
416.640 Use of benefit payments.
416.640a Compensation for qualified organizations serving as
representative payees.
416.641 Who is liable if your representative payee misuses your
benefits?
416.645 Conservation and investment of benefit payments.
416.650 When will we select a new representative payee for you?
416.655 When representative payment will be stopped.
416.660 Transfer of accumulated benefit payments.
416.665 How does your representative payee account for the use of
benefits?
Subpart G_Reports Required
Introduction
416.701 Scope of subpart.
416.702 Definitions.
Report Provisions
416.704 Who must make reports.
416.708 What you must report.
416.710 What reports must include.
416.712 Form of the report.
416.714 When reports are due.
Penalty Deductions
416.722 Circumstances under which we make a penalty deduction.
416.724 Amounts of penalty deductions.
416.726 Penalty period: First failure to report.
416.728 Penalty period: Second failure to report.
416.730 Penalty period: Three or more failures to report.
416.732 No penalty deduction if you have good cause for failure to
report timely.
Subpart H_Determination of Age
416.801 Evidence as to age--when required.
416.802 Type of evidence to be submitted.
416.803 Evaluation of evidence.
416.804 Certified copy in lieu of original.
416.805 When additional evidence may be required.
416.806 Expedited adjudication based on documentary evidence of age.
[[Page 820]]
Subpart I_Determining Disability and Blindness
General
416.901 Scope of subpart.
416.902 General definitions and terms for this subpart.
Determinations
416.903 Who makes disability and blindness determinations.
416.903a Program integrity.
416.904 Determinations by other organizations and agencies.
Definition of Disability
416.905 Basic definition of disability for adults.
416.906 Basic definition of disability for children.
416.907 Disability under a State plan.
416.908 What is needed to show an impairment.
416.909 How long the impairment must last.
416.910 Meaning of substantial gainful activity.
416.911 Definition of disabling impairment.
Evidence
416.912 Evidence.
416.913 Medical and other evidence of your impairment(s).
416.914 When we will purchase existing evidence.
416.915 Where and how to submit evidence.
416.916 If you fail to submit medical and other evidence.
416.917 Consultative examination at our expense.
416.918 If you do not appear at a consultative examination.
Standards To Be Used in Determining When a Consultative Examination Will
Be Obtained in Connection With Disability Determinations
416.919 The consultative examination.
416.919a When we will purchase a consultative examination and how we
will use it.
416.919b When we will not purchase a consultative examination.
Standards for the Type of Referral and for Report Content
416.919f Type of purchased examinations.
416.919g Who we will select to perform a consultative examination.
416.919h Your treating source.
416.919i Other sources for consultative examinations.
416.919j Objections to the medical source designated to perform the
consultative examination.
416.919k Purchase of medical examinations, laboratory tests, and other
services.
416.919m Diagnostic tests or procedures.
416.919n Informing the medical source of examination scheduling, report
content, and signature requirements.
416.919o When a properly signed consultative examination report has not
been received.
416.919p Reviewing reports of consultative examinations.
416.919q Conflict of interest.
Authorizing and Monitoring the Referral Process
416.919s Authorizing and monitoring the consultative examination.
Procedures To Monitor the Consultative Examination
416.919t Consultative examination oversight.
Evaluation of Disability
416.920 Evaluation of disability of adults, in general.
416.920a Evaluation of mental impairments.
416.921 What we mean by a not severe impairment(s) in an adult.
416.922 When you have two or more unrelated impairments--initial claims.
416.923 Multiple impairments.
416.924 How we determine disability for children.
416.924a Considerations in determining disability for children.
416.924b Age as a factor of evaluation in the sequential evaluation
process for children.
Medical Considerations
416.925 Listing of Impairments in appendix 1 of subpart P of part 404 of
this chapter.
416.926 Medical equivalence for adults and children.
416.926a Functional equivalence for children.
416.927 Evaluating opinion evidence.
416.928 Symptoms, signs, and laboratory findings.
416.929 How we evaluate symptoms, including pain.
416.930 Need to follow prescribed treatment.
Presumptive Disability and Blindness
416.931 The meaning of presumptive disability or presumptive blindness.
416.932 When presumptive payments begin and end.
416.933 How we make a finding of presumptive disability or presumptive
blindness.
416.934 Impairments which may warrant a finding of presumptive
disability or presumptive blindness.
[[Page 821]]
Drug Addiction and Alcoholism
416.935 How we will determine whether your drug addiction or alcoholism
is a contributing factor material to the determination of
disability.
416.936 Treatment required for individuals whose drug addiction or
alcoholism is a contributing factor material to the
determination of disability.
416.937 What we mean by appropriate treatment.
416.938 What we mean by approved institutions or facilities.
416.939 How we consider whether treatment is available.
416.940 Evaluating compliance with the treatment requirements.
416.941 Establishment and use of referral and monitoring agencies.
Residual Functional Capacity
416.945 Your residual functional capacity.
416.946 Responsibility for assessing your residual functional capacity.
Vocational Considerations
416.960 When we will consider your vocational background.
416.962 Medical-vocational profiles showing an inability to make an
adjustment to other work.
416.963 Your age as a vocational factor.
416.964 Your education as a vocational factor.
416.965 Your work experience as a vocational factor.
416.966 Work which exists in the national economy.
416.967 Physical exertion requirements.
416.968 Skill requirements.
416.969 Listing of Medical-Vocational Guidelines in appendix 2 of
subpart P of part 404 of this chapter.
416.969a Exertional and nonexertional limitations.
Substantial Gainful Activity
416.971 General.
416.972 What we mean by substantial gainful activity.
416.973 General information about work activity.
416.974 Evaluation guides if you are an employee.
416.974a When and how we will average your earnings.
416.975 Evaluation guides if you are self-employed.
416.976 Impairment-related work expenses.
Blindness
416.981 Meaning of blindness as defined in the law.
416.982 Blindness under a State plan.
416.983 How we evaluate statutory blindness.
416.984 If you are statutorily blind and still working.
416.985 How we evaluate other visual impairments.
416.986 Why and when we will find that you are no longer entitled to
benefits based on statutory blindness.
Disability Redeterminations for Individuals Who Attain Age 18
416.987 Disability redeterminations for individuals who attain age 18.
Continuing or Stopping Disability or Blindness
416.988 Your responsibility to tell us of events that may change your
disability or blindness status.
416.989 We may conduct a review to find out whether you continue to be
disabled.
416.989a We may conduct a review to find out whether you continue to be
blind.
416.990 When and how often we will conduct a continuing disability
review.
416.991 If your medical recovery was expected and you returned to work.
416.992 What happens if you fail to comply with our request for
information.
416.992a [Reserved]
416.993 Medical evidence in continuing disability review cases.
416.994 How we will decide whether your disability continues or ends,
disabled adults.
416.994a How we will determine whether your disability continues or
ends, and whether you are and have been receiving treatment
that is medically necessary and available, disabled children.
416.995 If we make a determination that your physical or mental
impairment(s) has ceased, did not exist or is no longer
disabling (Medical Cessation Determination).
416.996 Continued disability or blindness benefits pending appeal of a
medical cessation determination.
416.998 If you become disabled by another impairment(s).
416.999 What is expedited reinstatement?
416.999a Who is eligible for expedited reinstatement?
416.999b How do I request reinstatement?
416.999c How do we determine provisional benefits?
416.999d How do we determine reinstated benefits?
Subpart J_Determinations of Disability
General Provisions
416.1001 Purpose and scope.
416.1002 Definitions.
416.1003 Basic responsibilities for us and the State.
[[Page 822]]
Responsibilities for Performing the Disability Determination Function
416.1010 How a State notifies us that it wishes to perform the
disability determination function.
416.1011 How we notify a State whether it may perform the disability
determination function.
416.1013 Disability determinations the State makes.
416.1014 Responsibilities for obtaining evidence to make disability
determinations.
416.1015 Making disability determinations.
416.1016 Medical or psychological consultants.
416.1017 Reasonable efforts to obtain review by a qualified psychiatrist
or psychologist.
416.1018 Notifying claimant of the disability determination.
Administrative Responsibilities and Requirements
416.1020 General administrative requirements.
416.1021 Personnel.
416.1022 Training.
416.1023 Facilities.
416.1024 Medical and other purchased services.
416.1025 Records and reports.
416.1026 Fiscal.
416.1027 Audits.
416.1028 Property.
416.1029 Participation in research and demonstration projects.
416.1030 Coordination with other agencies.
416.1031 Confidentiality of information and records.
416.1032 Other Federal laws and regulations.
416.1033 Policies and operating instructions.
Performance Standards
416.1040 General.
416.1041 Standards of performance.
416.1042 Processing time standards.
416.1043 Performance accuracy standard.
416.1044 How and when we determine whether the processing time standards
are met.
416.1045 How and when we determine whether the performance accuracy
standard is met.
416.1050 Action we will take if a State agency does not meet the
standards.
Performance Monitoring and Support
416.1060 How we will monitor.
416.1061 When we will provide performance support.
416.1062 What support we will provide.
Substantial Failure
416.1070 General.
416.1071 Good cause for not following the Act, our regulations, or other
written guidelines.
416.1075 Finding of substantial failure.
Hearings and Appeals
416.1080 Notice of right to hearing on proposed finding of substantial
failure.
416.1081 Disputes on matters other than substantial failure.
416.1082 Who conducts the hearings.
416.1083 Hearings and appeals process.
Assumption of Disability Determination Function
416.1090 Assumption when we make a finding of substantial failure.
416.1091 Assumption when State no longer wishes to perform the
disability determination function.
416.1092 Protection of State employees.
416.1093 Limitation on State expenditures after notice.
416.1094 Final accounting by the State.
Subpart K_Income
General
416.1100 Income and SSI eligibility.
416.1101 Definition of terms.
416.1102 What is income?
416.1103 What is not income?
416.1104 Income we count.
Earned Income
416.1110 What is earned income.
416.1111 How we count earned income.
416.1112 Earned income we do not count.
Unearned Income
416.1120 What is unearned income.
416.1121 Types of unearned income.
416.1123 How we count unearned income.
416.1124 Unearned income we do not count.
In-Kind Support and Maintenance
416.1130 Introduction.
416.1131 The one-third reduction rule.
416.1132 What we mean by ``living in another person's household''.
416.1133 What is a pro rata share of household operating expenses.
416.1140 The presumed value rule.
416.1141 When the presumed value rule applies.
416.1142 If you live in a public assistance household.
416.1143 If you live in a noninstitutional care situation.
416.1144 If you live in a nonprofit retirement home or similar
institution.
416.1145 How the presumed value rule applies in a nonmedical for-profit
institution.
[[Page 823]]
In-Kind Support and Maintenance in Special Circumstances
416.1147 How we value in-kind support and maintenance for a couple.
416.1147a Income rules in change-of-status situations involving in-kind
support and maintenance.
416.1148 If you have both in-kind support and maintenance and income
that is deemed to you.
Temporary Absence
416.1149 What is a temporary absence from your living arrangement.
Disasters
416.1150 How we treat income received because of a major disaster.
416.1151 How we treat the repair or replacement of lost, damaged, or
stolen resources.
Home Energy Assistance
416.1157 Support and maintenance assistance.
Deeming of Income
416.1160 What is deeming of income.
416.1161 Income of an ineligible spouse, ineligible parent, and
essential person for deeming purposes.
416.1161a Income for deeming purposes where Medicaid eligibility is
affected.
416.1163 How we deem income to you from your ineligible spouse.
416.1165 How we deem income to you from your ineligible parent(s).
416.1166 How we deem income to you and your eligible child from your
ineligible spouse.
416.1166a How we deem income to you from your sponsor if you are an
alien.
416.1167 Temporary absences and deeming rules.
416.1168 How we deem income to you from your essential person.
416.1169 When we stop deeming income from an essential person.
Alternative Income Counting Rules for Certain Blind Individuals
416.1170 General.
416.1171 When the alternative rules apply.
Rules for Helping Blind and Disabled Individuals Achieve Self-Support
416.1180 General.
416.1181 What is a plan to achieve self-support (PASS)?
416.1182 When we begin to count the income excluded under the plan.
Appendix to Subpart K of Part 416--List of Types of Income Excluded
Under the SSI Program as Provided by Federal Laws Other Than
the Social Security Act
Subpart L_Resources and Exclusions
416.1201 Resources; general.
416.1202 Deeming of resources.
416.1203 Deeming of resources of an essential person.
416.1204 Deeming of resources of the sponsor of an alien.
416.1204a Deeming of resources where Medicaid eligibility is affected.
416.1205 Limitation on resources.
416.1207 Resources determinations.
416.1208 How funds held in financial institution accounts are counted.
416.1210 Exclusions from resources; general.
416.1212 Exclusion of the home.
416.1216 Exclusion of household goods and personal effects.
416.1218 Exclusion of the automobile.
416.1220 Property essential to self-support; general.
416.1222 How income-producing property essential to self-support is
counted.
416.1224 How nonbusiness property used to produce goods or services
essential to self-support is counted.
416.1225 An approved plan to achieve self-support; general.
416.1226 What is a plan to achieve self-support(PASS)?
416.1227 When the resources excluded under a plan to achieve self-
support begin to count.
416.1228 Exclusion of Alaskan natives' stock in regional or village
corporations.
416.1229 Exclusion of payments received as compensation for expenses
incurred or losses suffered as a result of a crime.
416.1230 Exclusion of life insurance.
416.1231 Burial spaces and certain funds set aside for burial expenses.
416.1232 Replacement of lost, damaged, or stolen excluded resources.
416.1233 Exclusion of certain underpayments from resources.
416.1234 Exclusion of Indian lands.
416.1235 Exclusion of earned income tax credit.
416.1236 Exclusions from resources; provided by other statutes.
416.1237 Assistance received on account of major disaster.
416.1238 Exclusion of certain housing assistance.
416.1239 Exclusion of State or local relocation assistance payments.
416.1240 Disposition of resources.
416.1242 Time limits for disposing of resources.
416.1244 Treatment of proceeds from disposition of resources.
416.1245 Exceptions to required disposition of real property.
[[Page 824]]
416.1246 Disposal of resources at less than fair market value.
416.1247 Exclusion of a dedicated account in a financial institution.
416.1248 Exclusion of gifts to children with life-threatening
conditions.
416.1249 Exclusion of payments received as restitution for misuse of
benefits by a representative payee.
416.1250 How we count grants, scholarships, fellowships or gifts.
416.1260 Special resource provision for recipients under a State plan.
416.1261 Application of special resource provision.
416.1262 Special resource provision applicable in cases involving
essential persons.
416.1264 Spouse ineligible under a State plan in December 1973.
416.1266 Individual under special resource provision dies after December
1973.
Subpart M_Suspensions and Terminations
416.1320 Suspensions; general.
416.1321 Suspension for not giving us permission to contact financial
institutions.
416.1322 Suspension due to failure to comply with request for
information.
416.1323 Suspension due to excess income.
416.1324 Suspension due to excess resources.
416.1325 Suspension due to status as a resident of a public institution.
416.1326 Suspension for failure to comply with treatment for drug
addiction or alcoholism.
416.1327 Suspension due to absence from the United States.
416.1329 Suspension due to loss of United States residency, United
States citizenship, or status as an alien lawfully admitted
for permanent residence or otherwise permanently residing in
the United States under color of law.
416.1330 Suspension due to failure to apply for and obtain other
benefits.
416.1331 Termination of your disability or blindness payments.
416.1332 Termination of benefit for disabled individual: Exception.
416.1333 Termination at the request of the recipient.
416.1334 Termination due to death of recipient.
416.1335 Termination due to continuous suspension.
416.1336 Notice of intended action affecting recipient's payment status.
416.1337 Exceptions to the continuation of previously established
payment level.
416.1338 If you are participating in an appropriate program of
vocational rehabilitation services, employment services, or
other support services.
416.1339 Suspension due to flight to avoid criminal prosecution or
custody or confinement after conviction, or due to violation
of probation or parole.
416.1340 Penalty for making false or misleading statements or
withholding information.
Subpart N_Determinations, Administrative Review Process, and Reopening
of Determinations and Decisions
Introduction, Definitions, and Initial Determinations
416.1400 Introduction.
416.1401 Definitions.
416.1402 Administrative actions that are initial determinations.
416.1403 Administrative actions that are not initial determinations.
416.1404 Notice of the initial determination.
416.1405 Effect of an initial determination.
416.1406 Testing modifications to the disability determination
procedures.
Reconsideration
416.1407 Reconsideration--general.
416.1408 Parties to a reconsideration.
416.1409 How to request reconsideration.
416.1411 Good cause for missing the deadline to request review.
416.1413 Reconsideration procedures.
416.1413a Reconsiderations of initial determinations on applications.
416.1413b Reconsideration procedures for post-eligibility claims.
416.1413c Arrangement for conferences.
416.1414 Disability hearing--general.
416.1415 Disability hearing--disability hearing officers.
416.1416 Disability hearing--procedures.
416.1417 Disability hearing--disability hearing officer's reconsidered
determination.
416.1418 Disability hearing--review of the disability hearing officer's
reconsidered determination before it is issued.
416.1419 Notice of another person's request for reconsideration.
416.1420 Reconsidered determination.
416.1421 Effect of a reconsidered determination.
416.1422 Notice of a reconsidered determination.
Expedited Appeals Process
416.1423 Expedited appeals process--general.
416.1424 When the expedited appeals process may be used.
416.1425 How to request expedited appeals process.
416.1426 Agreement in expedited appeals process.
416.1427 Effect of expedited appeals process agreement.
416.1428 Expedited appeals process request that does not result in
agreement.
[[Page 825]]
Hearing Before an Administrative Law Judge
416.1429 Hearing before an administrative law judge--general.
416.1430 Availability of a hearing before an administrative law judge.
416.1432 Parties to a hearing before an administrative law judge.
416.1433 How to request a hearing before an administrative law judge.
416.1435 Submitting evidence prior to a hearing before an administrative
law judge.
416.1436 Time and place for a hearing before an administrative law
judge.
416.1438 Notice of a hearing before an administrative law judge.
416.1439 Objections to the issues.
416.1440 Disqualification of the administrative law judge.
416.1441 Prehearing case review.
416.1442 Prehearing proceedings and decisions by attorney advisors.
416.1443 Responsibilities of the adjudication officer.
Administrative Law Judge Hearing Procedures
416.1444 Administrative law judge hearing procedures--general.
416.1446 Issues before an administrative law judge.
416.1448 Deciding a case without an oral hearing before an
administrative law judge.
416.1449 Presenting written statements and oral arguments.
416.1450 Presenting evidence at a hearing before an administrative law
judge.
416.1451 When a record of a hearing before an administrative law judge
is made.
416.1452 Consolidated hearings before an administrative law judge.
416.1453 The decision of an administrative law judge.
416.1455 The effect of an administrative law judge's decision.
416.1456 Removal of a hearing request from an administrative law judge
to the Appeals Council.
416.1457 Dismissal of a request for a hearing before an administrative
law judge.
416.1458 Notice of dismissal of a request for a hearing before an
administrative law judge.
416.1459 Effect of dismissal of a request for a hearing before an
administrative law judge.
416.1460 Vacating a dismissal of a request for a hearing before an
administrative law judge.
416.1461 Prehearing and posthearing conferences.
416.1465 [Reserved]
Appeals Council Review
416.1466 Testing elimination of the request for Appeals Council review.
416.1467 Appeals Council review--general.
416.1468 How to request Appeals Council review.
416.1469 Appeals Council initiates review.
416.1470 Cases the Appeals Council will review.
416.1471 Dismissal by Appeals Council.
416.1472 Effect of dismissal of request for Appeals Council review.
416.1473 Notice of Appeals Council review.
416.1474 Obtaining evidence from Appeals Council.
416.1475 Filing briefs with the Appeals Council.
416.1476 Procedures before Appeals Council on review.
416.1477 Case remanded by Appeals Council.
416.1479 Decision of Appeals Council.
416.1481 Effect of Appeals Council's decision or denial of review.
416.1482 Extension of time to file action in Federal district court.
Court Remand Cases
416.1483 Case remanded by a Federal court.
416.1484 Appeals Council review of administrative law judge decision in
a case remanded by a Federal court.
416.1485 Application of circuit court law.
Reopening and Revising Determinations and Decisions
416.1487 Reopening and revising determinations and decisions.
416.1488 Conditions for reopening.
416.1489 Good cause for reopening.
416.1491 Late completion of timely investigation.
416.1492 Notice of revised determination or decision.
416.1493 Effect of revised determination or decision.
416.1494 Time and place to request further review or a hearing on
revised determination or decision.
Payment of Certain Travel Expenses
416.1495 Payment of certain travel expenses--general.
416.1496 Who may be reimbursed.
416.1498 What travel expenses are reimbursable.
416.1499 When and how to claim reimbursement.
Subpart O_Representation of Parties
416.1500 Introduction.
416.1503 Definitions.
416.1505 Who may be your representative.
416.1506 Notification of options for obtaining attorney representation.
416.1507 Appointing a representative.
[[Page 826]]
416.1510 Authority of a representative.
416.1515 Notice or request to a representative.
416.1520 Fee for a representative's services.
416.1525 Request for approval of a fee.
416.1528 Proceedings before a State or Federal court.
416.1535 Services in a proceeding under title XVI of the Act.
416.1540 Rules of conduct and standards of responsibility for
representatives.
416.1545 Violations of our requirements, rules, or standards.
416.1550 Notice of charges against a representative.
416.1555 Withdrawing charges against a representative.
416.1565 Hearing on charges.
416.1570 Decision by hearing officer.
416.1575 Requesting review of the hearing officer's decision.
416.1576 Assignment of request for review of the hearing officer's
decision.
416.1580 Appeals Council's review of hearing officer's decision.
416.1585 Evidence permitted on review.
416.1590 Appeals Council's decision.
416.1595 When the Appeals Council will dismiss a request for review.
416.1597 Reinstatement after suspension--period of suspension expired.
416.1599 Reinstatement after suspension or disqualification--period of
suspension not expired.
Subpart P_Residence and Citizenship
416.1600 Introduction.
416.1601 Definitions and terms used in this subpart.
416.1603 How to prove you are a resident of the United States.
416.1610 How to prove you are a citizen or a national of the United
States.
416.1615 How to prove you are lawfully admitted for permanent residence
in the United States.
416.1618 When you are considered permanently residing in the United
States under color of law.
416.1619 When you cannot be considered permanently residing in the
United States under color of law.
Subpart Q_Referral of Persons Eligible for Supplemental Security Income
to Other Agencies
General
416.1701 Scope of subpart.
416.1705 Definitions.
Referral for Vocational Rehabilitation Services
416.1710 Whom we refer and when.
Referral for Treatment of Alcoholism or Drug Addiction
416.1720 Whom we refer.
416.1725 Effect of your failure to comply with treatment requirements
for your drug addiction or alcoholism.
Subpart R_Relationship
416.1801 Introduction.
Who Is Considered Your Spouse
416.1802 Effects of marriage on eligibility and amount of benefits.
416.1806 Whether you are married and who is your spouse.
416.1816 Information we need concerning marriage when you apply for SSI.
416.1821 Showing that you are married when you apply for SSI.
416.1826 Showing that you are not married when you apply for SSI.
416.1830 When we stop considering you and your spouse an eligible
couple.
416.1832 When we consider your marriage ended.
416.1835 Information we need about separation or end of marriage after
you become eligible for SSI.
Who Is Considered a Child
416.1851 Effects of being considered a child.
416.1856 Who is considered a child.
416.1861 Deciding whether you are a child: Are you a student?
416.1866 Deciding whether you are a child: Are you the head of a
household?
Who Is Considered a Student for Purposes of the Student Earned Income
Exclusion
416.1870 Effect of being considered a student.
416.1872 Who is considered a student.
416.1874 When we need evidence that you are a student.
Who Is Considered Your Parent
416.1876 Effects a parent (or parents) can have on the child's benefits.
416.1881 Deciding whether someone is your parent or stepparent.
Subpart S_Interim Assistance Provisions
Introduction
416.1901 Scope of subpart S.
416.1902 Definitions.
Authorizations
416.1904 Authorization to withhold SSI benefits.
416.1906 When your authorization is in effect.
416.1908 When we need another authorization.
[[Page 827]]
Interim Assistance Agreements
416.1910 Requirements for interim assistance agreement.
Appeals
416.1920 Your appeal rights in the State.
416.1922 Your appeal rights in SSA.
Subpart T_State Supplementation Provisions; Agreement; Payments
416.2001 State supplementary payments; general.
416.2005 Administration agreements with SSA.
416.2010 Essentials of the administration agreements.
416.2015 Establishing eligibility.
416.2020 Federally administered supplementary payments.
416.2025 Optional supplementation: Countable income.
416.2030 Optional supplementation: Variations in payments.
416.2035 Optional supplementation: Additional State options.
416.2040 Limitations on eligibility.
416.2045 Overpayments and underpayments; federally administered
supplementation.
416.2047 Waiver of State supplementary payments.
416.2050 Mandatory minimum State supplementation.
416.2055 Mandatory minimum supplementation reduced.
416.2060 Mandatory minimum supplementary payments not applicable.
416.2065 Mandatory minimum State supplementation: Agreement deemed.
416.2070 Mandatory supplementation: State compliance not applicable.
416.2075 Monitoring of mandatory minimum supplementary payments.
416.2090 State funds transferred for supplementary payments.
416.2095 Pass-along of Federal benefit increases.
416.2096 Basic pass-along rules.
416.2097 Combined supplementary/SSI payment levels.
416.2098 Supplementary payment levels.
416.2099 Compliance with pass-along.
Subpart U_Medicaid Eligibility Determinations
416.2101 Introduction.
416.2111 Conditions for our agreeing to make Medicaid eligibility
determinations.
416.2116 Medicaid eligibility determinations.
416.2130 Effect of the agreement and responsibilities of States.
416.2140 Liability for erroneous Medicaid eligibility determinations.
416.2145 Services other than Medicaid determinations.
416.2161 Charges to States.
416.2166 Changing the agreement.
416.2171 Duration of agreement.
416.2176 Disagreements between a State and us.
Subpart V_Payments for Vocational Rehabilitation Services
General Provisions
416.2201 General.
416.2202 Purpose and scope.
416.2203 Definitions.
416.2204 Participation by State VR agencies or alternate participants.
416.2206 Basic qualifications for alternate participants.
Payment Provisions
416.2208 Requirements for payment.
416.2209 Responsibility for making payment decisions.
416.2210 What we mean by ``SGA'' and by ``a continuous period of 9
months''.
416.2211 Criteria for determining when VR services will be considered to
have contributed to a continuous period of 9 months.
416.2212 Payment for VR services in a case where an individual continues
to receive disability or blindness benefits based on
participation in an approved VR program.
416.2214 Services for which payment may be made.
416.2215 When services must have been provided.
416.2216 When claims for payment for VR services must be made (filing
deadlines).
416.2217 What costs will be paid.
Administrative Provisions
416.2218 Applicability of these provisions to alternate participants.
416.2219 Method of payment.
416.2220 Audits.
416.2221 Validation reviews.
416.2222 Confidentiality of information and records.
416.2223 Other Federal laws and regulations.
416.2227 Resolution of disputes.
Editorial Note: Nomenclature changes to part 416 appear at 68 FR
53509, Sept. 11, 2003.
Subpart A_Introduction, General Provisions and Definitions
Authority: Secs. 702(a)(5) and 1601-1635 of the Social Security Act
(42 U.S.C. 902(a)(5) and 1381-133d); Sec.212, Pub. L. 93-66, 87 Stat.
155 (42 U.S.C. 1382 note); Sec.502(a), Pub. L. 94-241, 90 Stat. 268 (48
U.S.C. 1681 note).
[[Page 828]]
Source: 39 FR 28625, Aug. 9, 1974, unless otherwise noted.
Sec.416.101 Introduction.
The regulations in this part 416 (Regulations No. 16 of the Social
Security Administration) relate to the provisions of title XVI of the
Social Security Act as amended by section 301 of Pub. L. 92-603 enacted
October 30, 1972, and as may thereafter be amended. Title XVI
(Supplemental Security Income For The Aged, Blind, and Disabled) of the
Social Security Act, as amended, established a national program,
effective January 1, 1974, for the purpose of providing supplemental
security income to individuals who have attained age 65 or are blind or
disabled. The regulations in this part are divided into the following
subparts according to subject content:
(a) This subpart A contains this introduction, a statement of the
general purpose underlying the supplemental security income program,
general provisions applicable to the program and its administration, and
definitions and use of terms occurring throughout this part.
(b) Subpart B of this part covers in general the eligibility
requirements which must be met for benefits under the supplemental
security income program. It sets forth the requirements regarding
residence, citizenship, age, disability, or blindness, and describes the
conditions which bar eligibility and generally points up other
conditions of eligibility taken up in greater detail elsewhere in the
regulations (e.g., limitations on income and resources, receipt of
support and maintenance, etc.).
(c) Subpart C of this part sets forth the rules with respect to the
filing of applications, requests for withdrawal of applications,
cancellation of withdrawal requests and other similar requests.
(d) Subpart D of this part sets forth the rules for computing the
amount of benefits payable to an eligible individual and eligible
spouse.
(e) Subpart E of this part covers provisions with respect to
periodic payment of benefits, joint payments, payment of emergency cash
advances, payment of benefits prior to a determination of disability,
prohibition against transfer or assignment of benefits, adjustment and
waiver of overpayments, and payment of underpayments.
(f) Subpart F of this part contains provisions with respect to the
selection of representative payees to receive benefits on behalf of and
for the use of recipients and to the duties and responsibilities of
representative payees.
(g) Subpart G of this part sets forth rules with respect to the
reporting of events and circumstances affecting eligibility or the
amount of benefits payable.
(h) Subpart H of this part sets forth rules and guidelines for the
submittal and evaluation of evidence of age where age is pertinent to
establishing eligibility or the amount of benefits payable.
(i) Subpart I of this part sets forth the rules for establishing
disability or blindness where the establishment of disability or
blindness is pertinent to eligibility.
(j) Subpart J of this part sets forth the standards, requirements
and procedures for States making determinations of disability for the
Commissioner. It also sets out the Commissioner's responsibilities in
carrying out the disability determination function.
(k) Subpart K of this part defines income, earned income, and
unearned income and sets forth the statutory exclusions applicable to
earned and unearned income for the purpose of establishing eligibility
for and the amount of benefits payable.
(l) Subpart L of this part defines the term resources and sets forth
the statutory exclusions applicable to resources for the purpose of
determining eligibility.
(m) Subpart M of this part deals with events or circumstances
requiring suspension or termination of benefits.
(n) Subpart N of this part contains provisions with respect to
procedures for making determinations with respect to eligibility, amount
of benefits, representative payment, etc., notices of determinations,
rights of appeal and procedures applicable thereto, and other procedural
due process provisions.
(o) Subpart O of this part contains provisions applicable to
attorneys and
[[Page 829]]
other individuals who represent applicants in connection with claims for
benefits.
(p) Subpart P of this part sets forth the residence and citizenship
requirements that are pertinent to eligibility.
(q) Subpart Q of this part contains provisions with respect to the
referral of individuals for vocational rehabilitation, treatment for
alcoholism and drug addiction, and application for other benefits to
which an applicant may be potentially entitled.
(r) Subpart R of this part sets forth the rules for determining
marital and other family relationships where pertinent to the
establishment of eligibility for or the amount of benefits payable.
(s) Subpart S of this part explains interim assistance and how
benefits may be withheld to repay such assistance given by the State.
(t) Subpart T of this part contains provisions with respect to the
supplementation of Federal supplemental security income payments by
States, agreements for Federal administration of State supplementation
programs, and payment of State supplementary payments.
(u) Subpart U of this part contains provisions with respect to
agreements with States for Federal determination of Medicaid eligibility
of applicants for supplemental security income.
(v) Subpart V of this part explains when payments are made to State
vocational rehabilitation agencies (or alternate participants) for
vocational rehabilitation services.
[39 FR 28625, Aug. 9, 1974, as amended at 51 FR 11718, Apr. 7, 1986; 62
FR 38454, July 18, 1997]
Sec.416.105 Administration.
The Supplemental Security Income for the Aged, Blind, and Disabled
program is administered by the Social Security Administration.
[51 FR 11718, Apr. 7, 1986, as amended at 62 FR 38454, July 18, 1997]
Sec.416.110 Purpose of program.
The basic purpose underlying the supplemental security income
program is to assure a minimum level of income for people who are age 65
or over, or who are blind or disabled and who do not have sufficient
income and resources to maintain a standard of living at the established
Federal minimum income level. The supplemental security income program
replaces the financial assistance programs for the aged, blind, and
disabled in the 50 States and the District of Columbia for which grants
were made under the Social Security Act. Payments are financed from the
general funds of the United States Treasury. Several basic principles
underlie the program:
(a) Objective tests. The law provides that payments are to be made
to aged, blind, and disabled people who have income and resources below
specified amounts. This provides objective measurable standards for
determining each person's benefits.
(b) Legal right to payments. A person's rights to supplemental
security income payments--how much he gets and under what conditions--
are clearly defined in the law. The area of administrative discretion is
thus limited. If an applicant disagrees with the decision on his claim,
he can obtain an administrative review of the decision and if still not
satisfied, he may initiate court action.
(c) Protection of personal dignity. Under the Federal program,
payments are made under conditions that are as protective of people's
dignity as possible. No restrictions, implied or otherwise, are placed
on how recipients spend the Federal payments.
(d) Nationwide uniformity of standards. The eligibility requirements
and the Federal minimum income level are identical throughout the 50
States and the District of Columbia. This provides assurance of a
minimum income base on which States may build supplementary payments.
(e) Incentives to work and opportunities for rehabilitation. Payment
amounts are not reduced dollar-for-dollar for work income but some of an
applicant's income is counted toward the eligibility limit. Thus,
recipients are encouraged to work if they can. Blind and disabled
recipients with vocational rehabilitation potential are referred to the
appropriate State vocational rehabilitation agencies that offer
rehabilitation services to enable them to enter the labor market.
[[Page 830]]
(f) State supplementation and Medicaid determinations. (1) Federal
supplemental security income payments lessen the variations in levels of
assistance and provide a basic level of assistance throughout the
nation. States are required to provide mandatory minimum State
supplementary payments beginning January 1, 1974, to aged, blind, or
disabled recipients of assistance for the month of December 1973 under
such State's plan approved under title I, X, XIV, or XVI of the Act in
order for the State to be eligible to receive title XIX funds (see
subpart T of this part). These payments must be in an amount sufficient
to ensure that individuals who are converted to the new program will not
have their income reduced below what it was under the State program for
December 1973. In addition, each State may choose to provide more than
the Federal supplemental security income and/or mandatory minimum State
supplementary payment to whatever extent it finds appropriate in view of
the needs and resources of its citizens or it may choose to provide no
more than the mandatory minimum payment where applicable. States which
provide State supplementary payments can enter into agreements for
Federal administration of the mandatory and optional State supplementary
payments with the Federal Government paying the administrative costs. A
State which elects Federal administration of its supplementation program
must apply the same eligibility criteria (other than those pertaining to
income) applied to determine eligibility for the Federal portion of the
supplemental security income payment, except as provided in Sec.1616(c)
of the Act (see subpart T of this part). There is a limitation on the
amount payable to the Commissioner by a State for the amount of the
supplementary payments made on its behalf for any fiscal year pursuant
to the State's agreement with the Secretary. Such limitation on the
amount of reimbursement is related to the State's payment levels for
January 1972 and its total expenditures for calendar year 1972 for aid
and assistance under the appropriate State plan(s) (see subpart T of
this part).
(2) States with Medicaid eligibility requirements for the aged,
blind, and disabled that are identical (except as permitted by Sec.
416.2111) to the supplemental security income eligibility requirements
may elect to have the Social Security Administration determine Medicaid
eligibility under the State's program for recipients of supplemental
security income and recipients of a federally administered State
supplementary payment. The State would pay half of Social Security
Administration's incremental administrative costs arising from carrying
out the agreement.
[39 FR 28625, Aug. 9, 1974, as amended at 53 FR 12941, Apr. 20, 1988; 62
FR 38454, July 18, 1997]
Sec.416.120 General definitions and use of terms.
(a) Terms relating to acts and regulations. As used in this part:
(1) The Act means the Social Security Act as amended (42 U.S.C.
Chap. 7).
(2) Wherever a title is referred to, it means such title of the Act.
(3) Vocational Rehabilitation Act means the act approved June 2,
1920 (41 Stat. 735), 29 U.S.C. 31-42, as amended, and as may be amended
from time to time hereafter.
(b) Commissioner; Appeals Council; defined. As used in this part:
(1) Commissioner means the Commissioner of Social Security.
(2) Appeals Council means the Appeals Council of the Office of
Hearings and Appeals in the Social Security Administration or such
member or members thereof as may be designated by the Chairman.
(c) Miscellaneous. As used in this part unless otherwise indicated:
(1) Supplemental security income benefit means the amount to be paid
to an eligible individual (or eligible individual and his eligible
spouse) under title XVI of the Act.
(2) Income means the receipt by an individual of any property or
service which he can apply, either directly or by sale or conversion, to
meeting his basic needs (see subpart K of this part).
(3) Resources means cash or other liquid assets or any real or
personal property that an individual owns and could
[[Page 831]]
convert to cash to be used for support and maintenance (see Sec.
416.1201(a)).
(4) Attainment of age. An individual attains a given age on the
first moment of the day preceding the anniversary of his birth
corresponding to such age.
(5) Couple means an eligible individual and his eligible spouse.
(6) Institution (see Sec.416.201).
(7) Public institution (see Sec.416.201).
(8) Resident of a public institution (see Sec.416.201).
(9) State, unless otherwise indicated, means a State of the United
States, the District of Columbia, or effective January 9, 1978, the
Northern Mariana Islands.
(10) The term United States when used in a geographical sense means
the 50 States, the District of Columbia, and effective January 9, 1978,
the Northern Mariana Islands.
(11) Masculine gender includes the feminine, unless otherwise
indicated.
(12) Section means a section of the regulations in part 416 of this
chapter unless the context indicates otherwise.
(13) Eligible individual means an aged, blind, or disabled
individual who meets all the requirements for eligibility for benefits
under the supplemental security income program.
(14) Eligible spouse means an aged, blind, or disabled individual
who is the husband or wife of another aged, blind, or disabled
individual and who is living with that individual (see Sec.
416.1801(c)).
(d) Periods of limitation ending on nonwork days. Pursuant to the
Act, where any provision of title XVI, or any provision of another law
of the United States (other than the Internal Revenue Code of 1954)
relating to or changing the effect of title XVI, or any regulation of
the Commissioner issued under title XVI, provides for a period within
which an act is required to be done which affects eligibility for or the
amount of any benefit or payment under title XVI or is necessary to
establish or protect any rights under title XVI and such period ends on
a Saturday, Sunday, or Federal legal holiday or on any other day all or
part of which is declared to be a nonworkday for Federal employees by
statute or Executive Order, then such act shall be considered as done
within such period if it is done on the first day thereafter which is
not a Saturday, Sunday, or legal holiday or any other day all or part of
which is declared to be a nonworkday for Federal employees either by
statute or Executive Order. For purposes of this paragraph, the day on
which a period ends shall include the final day of any extended period
where such extension is authorized by law or by the Commissioner
pursuant to law. Such extension of any period of limitation does not
apply to periods during which an application for benefits or payments
may be accepted as such an application pursuant to subpart C of this
part.
[39 FR 28625, Aug. 9, 1974, as amended at 43 FR 25091, June 9, 1978; 51
FR 11719, Apr. 7, 1986; 60 FR 16374, Mar. 30, 1995; 62 FR 38454, July
18, 1997]
Sec.416.121 Receipt of aid or assistance for December 1973 under an
approved State plan under title I, X, XIV, or XVI of the Social
Security Act.
(a) Recipient of aid or assistance defined. As used in this part
416, the term individual who was a recipient of aid or assistance for
December 1973 under a State plan approved under title I, X, XIV, or XVI
of the Social Security Act means an individual who correctly received
aid or assistance under such plan for December 1973 even though such aid
or assistance may have been received subsequent to December 1973. It
also includes an individual who filed an application prior to January
1974 and was otherwise eligible for aid or assistance for December 1973
under the provisions of such State plan but did not in fact receive such
aid or assistance. It does not include an individual who received aid or
assistance because of the provisions of 45 CFR 205.10(a) (pertaining to
continuation of assistance until a fair hearing decision is rendered),
as in effect in December 1973, and with respect to whom it is
subsequently determined that such aid or assistance would not have been
received without application of the provisions of such 45 CFR 205.10(a).
(b) Aid or assistance defined. As used in this part 416, the term
aid or assistance means aid or assistance as defined
[[Page 832]]
in titles I, X, XIV, and XVI of the Social Security Act, as in effect in
December 1973, and such aid or assistance is eligible for Federal
financial participation in accordance with those titles and the
provisions of 45 CFR chapter II as in effect in December 1973.
(c) Determinations of receipt of aid or assistance for December
1973. For the purpose of application of the provisions of this part 416,
the determination as to whether an individual was a recipient of aid or
assistance for December 1973 under a State plan approved under title I,
X, XIV, or XVI of the Social Security Act will be made by the Social
Security Administration. In making such determination, the Social
Security Administration may take into consideration a prior
determination by the appropriate State agency as to whether the
individual was eligible for aid or assistance for December 1973 under
such State plan. Such prior determination, however, shall not be
considered as conclusive in determining whether an individual was a
recipient of aid or assistance for December 1973 under a State plan
approved under title I, X, XIV, or XVI of the Social Security Act for
purposes of application of the provisions of this part 416.
(d) Special provision for disabled recipients. For purposes of Sec.
416.907, the criteria and definitions enumerated in paragraphs (a)
through (c) of this section are applicable in determining whether an
individual was a recipient of aid or assistance (on the basis of
disability) under a State plan approved under title XIV or XVI of the
Act for a month prior to July 1973. It is not necessary that the aid or
assistance for December 1973 and for a month prior to July 1973 have
been paid under the State plan of the same State.
[39 FR 32024, Sept. 4, 1974; 39 FR 33207, Sept. 16, 1974, as amended at
51 FR 11719, Apr. 7, 1986]
Subpart B_Eligibility
Authority: Secs. 702(a)(5), 1110(b), 1602, 1611, 1614, 1619(a),
1631, and 1634 of the Social Security Act (42 U.S.C. 902(a)(5), 1310(b),
1381a, 1382, 1382c, 1382h(a), 1383, and 1383c); secs. 211 and 212, Pub.
L. 93-66, 87 Stat. 154 and 155 (42 U.S.C. 1382 note); Sec.502(a), Pub.
L. 94-241, 90 Stat. 268 (48 U.S.C. 1681 note); Sec.2, Pub. L. 99-643,
100 Stat. 3574 (42 U.S.C. 1382h note).
Source: 47 FR 3103, Jan. 22, 1982, unless otherwise noted.
General
Sec.416.200 Introduction.
You are eligible for SSI benefits if you meet all the basic
requirements listed in Sec.416.202. However, the first month for which
you may receive SSI benefits is the month after the month in which you
meet these eligibility requirements. (See Sec.416.501.) You must give
us any information we request and show us necessary documents or other
evidence to prove that you meet these requirements. We determine your
eligibility for each month on the basis of your countable income in that
month. You continue to be eligible unless you lose your eligibility
because you no longer meet the basic requirements or because of one of
the reasons given in Sec.Sec.416.207 through 416.216.
[64 FR 31972, June 15, 1999, as amended at 68 FR 53508, Sept. 11, 2003]
Sec.416.201 General definitions and terms used in this subpart.
Any 9-month period means any period of 9 full calendar months ending
with any full calendar month throughout which (as defined in Sec.
416.211) an individual is residing in a public emergency shelter for the
homeless (as defined in this section) and including the immediately
preceding 8 consecutive full calendar months. January 1988 is the
earliest possible month in any 9-month period.
Educational or vocational training means a recognized program for
the acquisition of knowledge or skills to prepare an individual for
gainful employment. For purposes of these regulations, educational or
vocational training does not include programs limited to the acquisition
of basic life skills including but not limited to eating and dressing.
Emergency shelter means a shelter for individuals whose homelessness
poses a threat to their lives or health.
Homeless individual is one who is not in the custody of any public
institution and has no currently usable place to live. By custody we
mean the care and
[[Page 833]]
control of an individual in a mandatory residency where the individual's
freedom to come and go as he or she chooses is restricted. An individual
in a public institution awaiting discharge and placement in the
community is in the custody of that institution until discharged and is
not homeless for purposes of this provision.
Institution means an establishment that makes available some
treatment or services in addition to food and shelter to four or more
persons who are not related to the proprietor.
Medical care facility means a hospital (defined in section 1861(e)
of the Act), a skilled nursing facility (defined in section 1861(j) of
the Act), or an intermediate care facility (defined in section 1905(c)
of the Act).
Public emergency shelter for the homeless means a public institution
or that part of a public institution used as an emergency shelter by the
Federal government, a State, or a political subdivision of a State,
primarily for making available on a temporary basis a place to sleep,
food, and some services or treatment to homeless individuals. A medical
facility (as defined in Sec.416.201) or any holding facility,
detoxification center, foster care facility, or the like that has
custody of the individual is not a public emergency shelter for the
homeless. Similarly, transitional living arrangements such as a halfway
house that are part of an insitution's plan to facilitate the
individual's adjustment to community living are not public emergency
shelters for the homeless.
Public institution means an institution that is operated by or
controlled by the Federal government, a State, or a political
subdivision of a State such as a city or county. The term public
institution does not include a publicly operated community residence
which serves 16 or fewer residents.
Resident of a public institution means a person who can receive
substantially all of his or her food and shelter while living in a
public institution. The person need not be receiving treatment and
services available in the institution and is a resident regardless of
whether the resident or anyone else pays for all food, shelter, and
other services in the institution. A person is not a resident of a
public institution if he or she is living in a public educational
institution for the primary purpose of receiving educational or
vocational training as defined in this section. A resident of a public
institution means the same thing as an inmate of a public institution as
used in section 1611(e)(1)(A) of the Social Security Act. (See Sec.
416.211(b), (c), and (d) of this subpart for exceptions to the general
limitation on the eligibility for Supplemental Security Income benefits
of individuals who are residents of a public institution.)
SSI means supplemental security income.
State assistance means payments made by a State to an aged, blind,
or disabled person under a State plan approved under title I, X, XIV, or
XVI (AABD) of the Social Security Act which was in effect before the SSI
Program.
We or Us means the Social Security Administration.
You or Your means the person who applies for or receives SSI
benefits or the person for whom an application is filed.
[47 FR 3103, Jan. 22, 1982, as amended at 49 FR 19639, May 19, 1984; 50
FR 48570, Nov. 26, 1985; 50 FR 51517, Dec. 18, 1985; 54 FR 19164, May 4,
1989]
Sec.416.202 Who may get SSI benefits.
You are eligible for SSI benefits if you meet all of the following
requirements:
(a) You are--
(1) Aged 65 or older (subpart H);
(2) Blind (subpart I); or
(3) Disabled (subpart I).
(b) You are a resident of the United States (Sec.416.1603), and--
(1) A citizen or a national of the United States (Sec.416.1610);
(2) An alien lawfully admitted for permanent residence in the United
States (Sec.416.1615);
(3) An alien permanently residing in the United States under color
of law (Sec.416.1618); or
(4) A child of armed forces personnel living overseas as described
in Sec.416.216.
(c) You do not have more income than is permitted (subparts K and
D).
(d) You do not have more resources than are permitted (subpart L).
[[Page 834]]
(e) You are disabled, drug addiction or alcoholism is a contributing
factor material to the determination of disability (see Sec.416.935),
and you have not previously received a total of 36 months of Social
Security benefit payments when appropriate treatment was available or 36
months of SSI benefits on the basis of disability where drug addiction
or alcoholism was a contributing factor material to the determination of
disability.
(f) You are not--
(1) Fleeing to avoid prosecution for a crime, or an attempt to
commit a crime, which is a felony under the laws of the place from which
you flee (or which, in the case of the State of New Jersey, is a high
misdemeanor under the laws of that State);
(2) Fleeing to avoid custody or confinement after conviction for a
crime, or an attempt to commit a crime, which is a felony under the laws
of the place from which you flee (or which, in the case of the State of
New Jersey, is a high misdemeanor under the laws of that State); or
(3) Violating a condition of probation or parole imposed under
Federal or State law.
(g) You file an application for SSI benefits (subpart C).
[47 FR 3103, Jan. 22, 1982, as amended at 58 FR 4897, Jan. 19, 1993; 60
FR 8149, Feb. 10, 1995; 61 FR 10277, Mar. 13, 1996; 65 FR 40495, June
30, 2000]
Sec.416.203 Initial determinations of SSI eligibility.
(a) What happens when you apply for SSI benefits. When you apply for
SSI benefits we will ask you for documents and any other information we
need to make sure you meet all the requirements. We will ask for
information about your income and resources and about other eligibility
requirements and you must answer completely. We will help you get any
documents you need but do not have.
(b) How we determine your eligibility for SSI benefits. We determine
that you are eligible for SSI benefits for a given month if you meet the
requirements in Sec.416.202 in that month. However, you cannot become
eligible for payment of SSI benefits until the month after the month in
which you first become eligible for SSI benefits (see Sec.416.501). In
addition, we usually determine the amount of your SSI benefits for a
month based on your income in an earlier month (see Sec.416.420).
Thus, it is possible for you to meet the eligibility requirements in a
given month but receive no benefit payment for that month.
[47 FR 3103, Jan. 22, 1982, as amended at 50 FR 48570, Nov. 26, 1985; 64
FR 31972, June 15, 1999]
Sec.416.204 Redeterminations of SSI eligibility.
(a) Redeterminations defined. A redetermination is a review of your
eligibility to make sure that you are still eligible and that you are
receiving the right amount of SSI benefits. This review deals with the
requirements for eligibility other than whether you are still disabled
or blind. Continuation of disability or blindness reviews are discussed
in Sec.Sec.416.989 and 416.990.
(b) When we make redeterminations. (1) We redetermine your
eligibility on a scheduled basis at periodic intervals. The length of
time between scheduled redeterminations varies depending on the
likelihood that your situation may change in a way that affects your
benefits.
(2) We may also redetermine your eligibility when you tell us (or we
otherwise learn) of a change in your situation which affects your
eligibility or the amount of your benefit.
(c) The period for which a redetermination applies: (1) The first
redetermination applies to--
(i) The month in which we make the redetermination;
(ii) All months beginning with the first day of the latest of the
following:
(A) The month of first eligibility or re-eligibility; or
(B) The month of application; or
(C) The month of deferred or updated development; and
(iii) Future months until the second redetermination.
(2) All other redeterminations apply to--
(i) The month in which we make the redetermination;
(ii) All months beginning with the first day of the month the last
redetermination was initiated; and
[[Page 835]]
(iii) Future months until the next redetermination.
(3) If we made two redeterminations which cover the same month, the
later redetermination is the one we apply to that month.
[47 FR 3103, Jan. 22, 1982, as amended at 50 FR 48570, Nov. 26, 1985; 58
FR 64893, Dec. 10, 1993]
Reasons Why You May Not Get SSI Benefits for Which You Are Otherwise
Eligible
Sec.416.207 You do not give us permission to contact financial institutions.
(a) To be eligible for SSI payments you must give us permission to
contact any financial institution and request any financial records that
financial institution may have about you. You must give us this
permission when you apply for SSI payments or when we ask for it at a
later time. You must also provide us with permission from anyone whose
income and resources we consider as being available to you, i.e.,
deemors (see Sec.Sec.416.1160, 416.1202, 416.1203, and 416.1204).
(b) Financial institution means any:
(1) Bank,
(2) Savings bank,
(3) Credit card issuer,
(4) Industrial loan company,
(5) Trust company,
(6) Savings association,
(7) Building and loan,
(8) Homestead association,
(9) Credit union,
(10) Consumer finance institution, or
(11) Any other financial institution as defined in section 1101(1)
of the Right to Financial Privacy Act.
(c) Financial record means an original of, a copy of, or information
known to have been derived from any record held by the financial
institution pertaining to your relationship with the financial
institution.
(d) We may ask any financial institution for information on any
financial account concerning you. We may also ask for information on any
financial accounts for anyone whose income and resources we consider as
being available to you (see Sec.Sec.416.1160, 416.1202, 416.1203, and
416.1204).
(e) We ask financial institutions for this information when we think
that it is necessary to determine your SSI eligibility or payment
amount.
(f) Your permission to contact financial institutions, and the
permission of anyone whose income and resources we consider as being
available to you, i.e., a deemor (see Sec.Sec.416.1160, 416.1202,
416.1203, and 416.1204), remains in effect until a terminating event
occurs. The following terminating events only apply prospectively and do
not invalidate the permission for past periods.
(1) You cancel your permission in writing and provide the writing to
us.
(2) The deemor cancels their permission in writing and provides the
writing to us.
(3) The basis on which we consider a deemor's income and resources
available to you ends, e.g. when spouses separate or divorce or a child
attains age 18.
(4) Your application for SSI is denied, and the denial is final. A
denial is final when made, unless you appeal the denial timely as
described in Sec.Sec.416.1400 through 416.1499.
(5) You are no longer eligible for SSI as described in Sec.Sec.
416.1331 through 416.1335.
(g) If you don't give us permission to contact any financial
institution and request any financial records about you when we think it
is necessary to determine your SSI eligibility or payment amount, or if
you cancel the permission, you cannot be eligible for SSI payments.
Also, except as noted in paragraph (h), if anyone whose income and
resources we consider as being available to you (see Sec.Sec.
416.1160, 416.1202, 416.1203, and 416.1204) doesn't give us permission
to contact any financial institution and request any financial records
about that person when we think it is necessary to determine your
eligibility or payment amount, or if that person cancels the permission,
you cannot be eligible for SSI payments. This means that if you are
applying for SSI payments, you cannot receive them. If you are receiving
SSI payments, we will stop your payments.
(h) You may be eligible for SSI payments if there is good cause for
your being unable to obtain permission for us to contact any financial
institution
[[Page 836]]
and request any financial records about someone whose income and
resources we consider as being available to you (see Sec.Sec.
416.1160, 416.1202, 416.1203, and 416.1204).
(1) Good cause exists if permission cannot be obtained from the
individual and there is evidence that the individual is harassing you,
abusing you, or endangering your life.
(2) Good cause may exist if an individual other than one listed in
paragraph (h)(3) of this section refuses to provide permission and: you
acted in good faith to obtain permission from the individual but were
unable to do so through no fault of your own, or you cooperated with us
in our efforts to obtain permission.
(3) Good cause does not apply if the individual is your
representative payee and your legal guardian, if you are a minor child
and the individual is your representative payee and your custodial
parent, or if you are an alien and the individual is your sponsor or the
sponsor's living-with spouse.
[68 FR 53508, Sept. 11, 2003]
Sec.416.210 You do not apply for other benefits.
(a) General rule. You are not eligible for SSI benefits if you do
not apply for all other benefits for which you may be eligible.
(b) What ``other benefits'' includes. ``Other benefits'' includes
any payments for which you can apply that are available to you on an
ongoing or one-time basis of a type that includes annuities, pensions,
retirement benefits, or disability benefits. For example, ``other
benefits'' includes veterans' compensation and pensions, workers'
compensation payments, Social Security insurance benefits and
unemployment insurance benefits. ``Other benefits'' for which you are
required to apply do not include payments that you may be eligible to
receive from a fund established by a State to aid victims of crime. (See
Sec.416.1124(c)(17).)
(c) Our notice to you. We will give you a dated, written notice that
will tell you about any other benefits that we think you are likely to
be eligible for. In addition, the notice will explain that your
eligibility for SSI benefits will be affected if you do not apply for
those other benefits.
(d) What you must do to apply for other benefits. In order to apply
for other benefits, you must file any required applications and do
whatever else is needed so that your eligibility for the other benefits
can be determined. For example, if any documents (such as a copy of a
birth certificate) are required in addition to the application, you must
submit them.
(e) What happens if you do not apply for the other benefits. (1) If
you do not apply for the other benefits within 30 days from the day that
you receive our written notice, you are not eligible for SSI benefits.
This means that if you are applying for SSI benefits, you cannot receive
them. If you are receiving SSI benefits, your SSI benefits will stop. In
addition, you will have to repay us for any SSI benefits that you
received beginning with the month that you received our written notice.
We assume (unless you prove otherwise) that you received our written
notice 5 days after the date shown on the notice. We will also find that
you are not eligible for SSI benefits if you file the required
application for other benefits but do not take other necessary steps to
obtain them.
(2) We will not find you ineligible for SSI benefits if you have a
good reason for not applying for the other benefits within the 30-day
period or taking other necessary steps to obtain them. In determining
whether a good reason exists, we will take into account any physical,
mental, educational, or linguistic limitations (including any lack of
facility with the English language) which may have caused you to fail to
apply for other benefits. You may have a good reason if, for example--
(i) You are incapacitated (because of illness you were not able to
apply); or
(ii) It would be useless for you to apply (you once applied for the
benefits and the reasons why you were turned down have not changed).
[47 FR 3103, Jan. 22, 1982, as amended at 50 FR 5573, Feb. 11, 1985; 50
FR 14211, April 11, 1985; 59 FR 1635, Jan. 12, 1994; 61 FR 1712, Jan.
23, 1996]
[[Page 837]]
Sec.416.211 You are a resident of a public institution.
(a) General rule. (1) Subject to the exceptions described in
paragraphs (b), (c), and (d) of this section and Sec.416.212, you are
not eligible for SSI benefits for any month throughout which you are a
resident of a public institution as defined in Sec.416.201. In
addition, if you are a resident of a public institution when you apply
for SSI benefits and meet all other eligibility requirements, you cannot
be eligible for payment of benefits until the first day of the month
following the day of your release from the institution.
(2) By throughout a month we mean that you reside in an institution
as of the beginning of a month and stay the entire month. If you have
been a resident of a public institution, you remain a resident if you
are transferred from one public institution to another or if you are
temporarily absent for a period of not more than 14 consecutive days. A
person also is a resident of an institution throughout a month if he or
she is born in the institution during the month and resides in the
institution the rest of the month or resides in the institution as of
the beginning of a month and dies in the institution during the month.
(b) Exception--SSI benefits payable at a reduced rate. You may be
eligible for SSI benefits at a reduced rate described in Sec.416.414,
if--
(1)(i) You reside throughout a month in a public institution that is
a medical care facility where Medicaid (title XIX of the Social Security
Act) pays a substantial part (more than 50 percent) of the cost of your
care; you are a child under the age of 18 residing throughout a month in
a public institution that is a medical care facility where a substantial
part (more than 50 percent) of the cost of your care is paid under a
health insurance policy issued by a private provider of such insurance;
or, you are a child under the age of 18 residing throughout a month in a
public institution that is a medical care facility where a substantial
part (more than 50 percent) of the cost of your care is paid by a
combination of Medicaid payments and payments made under a health
insurance policy issued by a private provider of such insurance; or
(ii) You reside for part of a month in a public institution and the
rest of the month in a public institution or private medical facility
where Medicaid pays a substantial part (more than 50 percent) of the
cost of your care; you are a child under the age of 18 residing for part
of a month in a public institution and the rest of the month in a public
institution or private medical facility where a substantial part (more
than 50 percent) of the cost of your care is paid under a health
insurance policy issued by a private provider of such insurance; or you
are a child under the age of 18 residing for part of a month in a public
institution and the rest of the month in a public institution or private
medical facility where a substantial part (more than 50 percent) of the
cost of your care is paid by a combination of Medicaid payments and
payments made under a health insurance policy issued by a private
provider; and
(2) You are ineligible in that month for a benefit described in
Sec.416.212 that is payable to a person temporarily confined in a
medical facility.
(c) Exception for publicly operated community residences which serve
no more than 16 residents--(1) General rule. If you are a resident of a
publicly operated community residence which serves no more than 16
residents, you may be eligible for SSI benefits.
(2) Services that a facility must provide in order to be a community
residence. To be a community residence, a facility must provide food and
shelter. In addition, it must make available some other services. For
example, the other services could be--
(i) Social services;
(ii) Help with personal living activities;
(iii) Training in socialization and life skills; or
(iv) Providing occasional or incidental medical or remedial care.
(3) Serving no more than 16 residents. A community residence serves
no more than 16 residents if--
(i) It is designed and planned to serve no more than 16 residents,
or the design and plan were changed to serve no more than 16 residents;
and
(ii) It is in fact serving 16 or fewer residents.
[[Page 838]]
(4) Publicly operated. A community residence is publicly operated if
it is operated or controlled by the Federal government, a State, or a
political subdivision of a State such as a city or county.
(5) Facilities which are not a publicly operated community
residence. If you live in any of the following facilities, you are not a
resident of a publicly operated community residence:
(i) A residential facility which is on the grounds of or next to a
large institution or multipurpose complex;
(ii) An educational or vocational training institution whose main
function is to provide an approved, accredited, or recognized program to
some or all of those who live there;
(iii) A jail or other facility where the personal freedom of anyone
who lives there is restricted because that person is a prisoner, is
being held under court order, or is being held until charges against
that person are disposed of; or
(iv) A medical care facility (defined in Sec.416.201).
(d) Exception for residents of public emergency shelters for the
homeless. For months after December 1987, if you are a resident of a
public emergency shelter for the homeless (defined in Sec.416.201) you
may be eligible for SSI benefits for any 6 months throughout which you
reside in a shelter in any 9-month period (defined in Sec.416.201).
The 6 months do not need to be consecutive and we will not count as part
of the 6 months any prior months throughout which you lived in the
shelter but did not receive SSI benefits. We will also not count any
months throughout which you lived in the shelter and received SSI
benefits prior to January 1988.
Example: You are receiving SSI benefits when you lose your home and
enter a public emergency shelter for the homeless on March 10, 1988. You
remain a resident of a shelter until October 10, 1988. Since you were
not in the shelter throughout the month of March, you are eligible to
receive your benefit for March without having this month count towards
the 6-month period. The last full month throughout which you reside in
the shelter is September 1988. Therefore, if you meet all eligibility
requirements, you will also be paid benefits for April through September
(6 months during the 9-month period September 1988 back through January
1988). If you are otherwise eligible, you will receive your SSI benefit
for October when you left the shelter, since you were not a resident of
the shelter throughout that month.
[47 FR 3103, Jan. 22, 1982, as amended at 50 FR 51518, Dec. 18, 1985; 51
FR 13492, Apr. 21, 1986; 51 FR 17332, May 12, 1986; 51 FR 34464, Sept.
29, 1986; 54 FR 19164, May 4, 1989; 61 FR 10277, Mar. 13, 1996; 62 FR
1055, Jan. 8, 1997; 64 FR 31972, June 15, 1999]
Sec.416.212 Continuation of full benefits in certain cases of
medical confinement.
(a) Benefits payable under section 1611(e)(1)(E) of the Social
Security Act. Subject to eligibility and regular computation rules (see
subparts B and D of this part), you are eligible for the benefits
payable under section 1611(e)(1)(E) of the Social Security Act for up to
2 full months of medical confinement during which your benefits would
otherwise be suspended because of residence in a public institution or
reduced because of residence in a public or private institution where
Medicaid pays a substantial part (more than 50 percent) of the cost of
your care or, if you are a child under age 18, reduced because of
residence in a public or private institution which receives payments
under a health insurance policy issued by a private provider, or a
combination of Medicaid and a health insurance policy issued by a
private provider, pay a substantial part (more than 50 percent) of the
cost of your care if--
(1) You were eligible under either section 1619(a) or section
1619(b) of the Social Security Act in the month before the first full
month of residence in an institution;
(2) The institution agrees that no portion of these benefits will be
paid to or retained by the institution excepting nominal sums for
reimbursement of the institution for any outlay for a recipient's
personal needs (e.g., personal hygiene items, snacks, candy); and
(3) The month of your institutionalization is one of the first 2
full months of a continuous period of confinement.
(b) Benefits payable under section 1611(e)(1)(G) of the Social
Security Act. (1) Subject to eligibility and regular computation rules
(see subparts B and D of this part), you are eligible for the benefits
payable under section 1611(e)(1)(G)
[[Page 839]]
of the Social Security Act for up to 3 full months of medical
confinement during which your benefits would otherwise be suspended
because of residence in a public institution or reduced because of
residence in a public or private institution where Medicaid pays a
substantial part (more than 50 percent) of the cost of your care or, if
you are a child under age 18, reduced because of residence in a public
institution which receives payments under a health insurance policy
issued by a private provider, or a combination of Medicaid and a health
insurance policy issued by a private provider, pay a substantial part
(more than 50 percent) of the cost of your care if--
(i) You were eligible for SSI cash benefits and/or federally
administered State supplementary payments for the month immediately
prior to the first full month you were a resident in such institution;
(ii) The month of your institutionalization is one of the first 3
full months of a continuous period of confinement;
(iii) A physician certifies, in writing, that you are not likely to
be confined for longer than 90 full consecutive days following the day
you entered the institution, and the certification is submitted to SSA
no later than the day of discharge or the 90th full day of confinement,
whichever is earlier; and
(iv) You need to pay expenses to maintain the home or living
arrangement to which you intend to return after institutionalization and
evidence regarding your need to pay these expenses is submitted to SSA
no later than the day of discharge or the 90th full day of confinement,
whichever is earlier.
(2) We will determine the date of submission of the evidence
required in paragraphs (b)(1) (iii) and (iv) of this section to be the
date we receive it or, if mailed, the date of the postmark.
(c) Prohibition against using benefits for current maintenance. If
the recipient is a resident in an institution, the recipient or his or
her representative payee will not be permitted to pay the institution
any portion of benefits payable under section 1611(e)(1)(G) excepting
nominal sums for reimbursement of the institution for any outlay for the
recipient's personal needs (e.g., personal hygiene items, snacks,
candy). If the institution is the representative payee, it will not be
permitted to retain any portion of these benefits for the cost of the
recipient's current maintenance excepting nominal sums for reimbursement
for outlays for the recipient's personal needs.
[61 FR 10277, Mar. 13, 1996, as amended at 62 FR 1055, Jan. 8, 1997]
Sec.416.214 You are disabled and drug addiction or alcoholism is a
contributing factor material to the determination of disability.
(a) If you do not comply with treatment requirements. If you receive
benefits because you are disabled and drug addiction or alcoholism is a
contributing factor material to the determination of disability (see
Sec.416.935), you must avail yourself of any appropriate treatment for
your drug addiction or alcoholism at an approved institution or facility
when this treatment is available and make progress in your treatment.
You are not eligible for SSI benefits beginning with the month after the
month you are notified in writing that we determined that you have
failed to comply with the treatment requirements. If your benefits are
suspended because you failed to comply with treatment requirements, you
will not be eligible to receive benefits until you have demonstrated
compliance with treatment for a period of time, as specified in Sec.
416.1326. The rules regarding treatment for drug addiction and
alcoholism are in subpart I of this part.
(b) If you previously received 36 months of SSI or Social Security
benefits. You are not eligible for SSI benefits by reason of disability
on the basis of drug addiction or alcoholism as described in Sec.
416.935 if--
(1) You previously received a total of 36 months of SSI benefits on
the basis of disability and drug addiction or alcoholism was a
contributing factor material to the determination of disability for
months beginning March 1995, as described in Sec.416.935. Not included
in these 36 months are months before March 1995 and months for which
your benefits were suspended for any reason. The 36-month limit is no
longer effective for months beginning after September 2004; or
[[Page 840]]
(2) You previously received a total of 36 months of Social Security
benefits counted in accordance with the provisions of Sec.Sec.
404.316, 404.337, and 404.352 by reason of disability on the basis of
drug addiction or alcoholism as described in Sec.404.1535.
[60 FR 8149, Feb. 10, 1995. Redesignated at 61 FR 10277, Mar. 13, 1996]
Sec.416.215 You leave the United States.
You lose your eligibility for SSI benefits for any month during all
of which you are outside of the United States. If you are outside of the
United States for 30 days or more in a row, you are not considered to be
back in the United States until you are back for 30 days in a row. You
may again be eligible for SSI benefits in the month in which the 30 days
end if you continue to meet all other eligibility requirements.
By United States, we mean the 50 States, the District of Columbia, and
the Northern Mariana Islands.
[47 FR 3103, Jan. 22, 1982. Redesignated at 61 FR 10277, Mar. 13, 1996]
Sec.416.216 You are a child of armed forces personnel living overseas.
(a) General rule. For purposes of this part, overseas means any
location outside the United States as defined in Sec.416.215; i.e.,
the 50 States, the District of Columbia and the Northern Mariana
Islands. You may be eligible for SSI benefits if you live overseas and
if--
(1) You are a child as described in Sec.416.1856;
(2) You are a citizen of the United States; and
(3) You are living with a parent as described in Sec.416.1881 who
is a member of the armed forces of the United States assigned to
permanent duty ashore overseas.
(b) Living with. You are considered to be living with your parent
who is a member of the armed forces if--
(1) You physically live with the parent who is a member of the armed
forces overseas; or
(2) You are not living in the same household as the military parent
but your presence overseas is due to his or her permanent duty
assignment.
[58 FR 4897, Jan. 19, 1993; 58 FR 9597, Feb. 22, 1993, as amended at 59
FR 41400, Aug. 12, 1994. Redesignated at 61 FR 10277, Mar. 13, 1996; 70
FR 61366, Oct. 24, 2005]
Eligibility for Increased Benefits Because of Essential Persons
Sec.416.220 General.
If you are a qualified individual and have an essential person you
may be eligible for increased benefits. You may be a qualified
individual and have an essential person only if you received benefits
under a State assistance plan approved under title I, X, XIV, or XVI
(AABD) of the Act for December 1973. Definitions and rules that apply to
qualified individuals and essential persons are discussed in Sec.Sec.
416.221 through 416.223.
Sec.416.221 Who is a qualified individual.
You are a qualified individual if--
(a) You received aid or assistance for the month of December 1973
under a State plan approved under title I, X, XIV, or XVI (AABD) of the
Act;
(b) The State took into account the needs of another person in
deciding your need for the State assistance for December 1973;
(c) That other person was living in your home in December 1973; and
(d) That other person was not eligible for State assistance for
December 1973.
Sec.416.222 Who is an essential person.
(a) General rule. A person is an essential person if--
(1) That person has continuously lived in the home of the same
qualified individual since December 1973;
(2) That person was not eligible for State assistance for December
1973;
(3) That person was never eligible for SSI benefits in his or her
own right or as an eligible spouse; and
(4) There are State records which show that under a State plan in
effect for June 1973, the State took that person's needs into account in
determining the qualified individual's need for State assistance for
December 1973.
Any person who meets these requirements is an essential person. This
[[Page 841]]
means that the qualified individual can have more than one essential
person.
(b) Absence of an essential person from the home of a qualified
individual. An essential person may be temporarily absent from the house
of a qualified individual and still be an essential person. For example,
the essential person could be hospitalized. We consider an absence to
temporary if--
(1) The essential person intends to return;
(2) The facts support this intention;
(3) It is likely that he or she will return; and
(4) The absence is not longer than 90 days.
(c) Absence of a qualified individual from his or her home. You may
be temporarily absent from your home and still have an essential person.
For example, you could be hospitalized. We consider an absence to be
temporary if--
(1) You intend to return;
(2) The facts support your intention;
(3) It is likely that you will return; and
(4) Your absence does not exceed six months.
(d) Essential person becomes eligible for SSI benefits. If an
essential person becomes eligible for SSI benefits, he or she will no
longer be an essential person beginning with the month that he or she
becomes eligible for the SSI benefits.
Sec.416.223 What happens if you are a qualified individual.
(a) Increased SSI benefits. We may increase the amount of your SSI
benefits if--
(1) You are a qualified individual; and
(2) You have one or more essential persons in your home.
In subpart D, we explain how these increased benefits are calculated.
(b) Income and resource limits. If you are a qualified individual,
we consider the income and resources of an essential person in your home
to be yours. You are eligible for increased SSI benefits if--
(1) Your resources which are counted do not exceed the limit for SSI
eligibility purposes (see subpart L); and
(2) Your income which is counted for SSI eligibility purposes (see
subpart K) does not exceed the sum of--
(i) The SSI Federal benefit rate (see subpart D); and
(ii) The proper number of essential person increments (for the value
of an essential person increment see subpart D). One essential person
increment is added to the SSI Federal benefit rate for each essential
person in your home.
(c) Excluding the income and resources of an essential person. (1)
While an essential person increment increases your SSI Federal benefit
rate, that person's income which we consider to be yours may actually
result in a lower monthly payment to you. We will discuss this with you
and explain how an essential person affects your benefit. If you choose
to do so, you may ask us in writing to determine your eligibility
without your essential person or, if you have more than one essential
person, without one or more of your essential persons. We will then
figure the amount of your SSI benefits without counting as your own
income and resources of the essential persons that you specify and we
will end the essential person increment for those essential persons. You
should consider this carefully because once you make the request, you
cannot withdraw it. We will make the change beginning with the month
following the month that you make the request.
(2) We will not include the income and resources of the essential
person if the person's income or resources would cause you to lose your
eligibility. The loss of the essential person increment will be
permanent.
Sec.416.250 Experimental, pilot, and demonstration projects in the
SSI program.
(a) Authority and purpose. Section 1110(b) of the Act authorizes the
Commissioner to develop and conduct experimental, pilot, and
demonstration projects to promote the objectives or improve the
administration of the SSI program. These projects will test the
advantages of altering certain requirements, conditions, or limitations
for recipients and test different administrative methods that apply to
title XVI applicants and recipients.
[[Page 842]]
(b) Altering benefit requirements, limitations or conditions.
Notwithstanding any other provision of this part, the Commissioner is
authorized to waive any of the requirements, limitations or conditions
established under title XVI of the Act and impose additional
requirements, limitations or conditions for the purpose of conducting
experimental, pilot, or demonstration projects. The projects will alter
the provisions that currently apply to applicants and recipients to test
their effect on the program. If, as a result of participation in a
project under this section, a project participant becomes ineligible for
Medicaid benefits, the Commissioner shall make arrangements to extend
Medicaid coverage to such participant and shall reimburse the States for
any additional expenses incurred due to such continued participation.
(c) Applicability and scope--(1) Participants and nonparticipants.
If you are selected to participate in an experimental, pilot, or
demonstration project, we may temporarily set aside one or more current
requirements, limitations or conditions of eligibility and apply
alternative provisions to you. We may also modify current methods of
administering title XVI as part of a project and apply alternative
procedures or policies to you. The alternative provisions or methods of
administration used in the projects will not substantially reduce your
total income or resources as a result of your participation or
disadvantage you in comparison to current provisions, policies, or
procedures. If you are not selected to participate in the experimental,
or pilot, or demonstration projects (or if you are placed in a control
group which is not subject to the alternative requirements, limitations,
or conditions) we will continue to apply the current requirements,
limitations or conditions of eligibility to you.
(2) Alternative provisions or methods of administration. The
alternative requirements, limitations or conditions that apply to you in
an experimental, pilot, or demonstration project may include any of the
factors needed for aged, blind, or disabled persons to be eligible for
SSI benefits. Experiments that we conduct will include, to the extent
feasible, applicants and recipients who are under age 18 as well as
adults and will include projects to ascertain the feasibility of
treating drug addicts and alcoholics.
(d) Selection of participants. Participation in the SSI project will
be on a voluntary basis. The voluntary written consent necessary in
order to participate in any experimental, pilot, or demonstration
project may be revoked by the participant at any time.
(e) Duration of experimental, pilot, and demonstration projects. A
notice describing each experimental, pilot, or demonstration project
will be published in the Federal Register before each project is placed
in operation. Each experimental, pilot and demonstration project will
have a termination date (up to 10 years from the start of the project).
[48 FR 7576, Feb. 23, 1983, as amended at 52 FR 37605, Oct. 8, 1987; 62
FR 38454, July 18, 1997]
Special Provisions for People Who Work Despite a Disabling Impairment
Sec.416.260 General.
The regulations in Sec.Sec.416.260 through 416.269 describe the
rules for determining eligibility for special SSI cash benefits and for
special SSI eligibility status for an individual who works despite a
disabling impairment. Under these rules an individual who works despite
a disabling impairment may qualify for special SSI cash benefits and in
most cases for Medicaid benefits when his or her gross earned income
exceeds the applicable dollar amount which ordinarily represents SGA
described in Sec.416.974(b)(2). The calculation of this gross earned
income amount, however, is not to be considered an actual SGA
determination. Also, for purposes of determining eligibility or
continuing eligibility for Medicaid benefits, a blind or disabled
individual (no longer eligible for regular SSI benefits or for special
SSI cash benefits) who, except for earnings, would otherwise be eligible
for SSI cash benefits may be eligible for a special SSI eligibility
status under which he or she is considered to be a blind or disabled
individual receiving SSI benefits. We explain the rules
[[Page 843]]
for eligibility for special SSI cash benefits in Sec.Sec.416.261 and
416.262. We explain the rules for the special SSI eligibility status in
Sec.Sec.416.264 through 416.269.
[59 FR 41403, Aug. 12, 1994]
Sec.416.261 What are special SSI cash benefits and when are they payable.
Special SSI cash benefits are benefits that we may pay you in lieu
of regular SSI benefits because your gross earned income in a month of
initial eligibility for regular SSI benefits exceeds the amount
ordinarily considered to represent SGA under Sec.416.974(b)(2). You
must meet the eligibility requirements in Sec.416.262 in order to
receive special SSI cash benefits. Special SSI cash benefits are not
payable for any month in which your countable income exceeds the limits
established for the SSI program (see subpart K of this part). If you are
eligible for special SSI cash benefits, we consider you to be a disabled
individual receiving SSI benefits for purposes of eligibility for
Medicaid. We compute the amount of special SSI cash benefits according
to the rules in subpart D of this part. If your State makes
supplementary payments which we administer under a Federal-State
agreement, and if your State elects to supplement the special SSI cash
benefits, the rules in subpart T of this part will apply to these
payments.
[47 FR 15324, Apr. 9, 1982, as amended at 50 FR 46763, Nov. 13, 1985; 59
FR 41403, Aug. 12, 1994]
Sec.416.262 Eligibility requirements for special SSI cash benefits.
You are eligible for special SSI cash benefits if you meet the
following requirements--
(a) You were eligible to receive a regular SSI benefit or a
federally administered State supplementary payment (see Sec.416.2001)
in a month before the month for which we are determining your
eligibility for special SSI cash benefits as long as that month was not
in a prior period of eligibility which has terminated according to
Sec.Sec.416.1331 through 416.1335;
(b) In the month for which we are making the determination, your
gross earned income exceeds the amount ordinarily considered to
represent SGA under Sec.416.974(b)(2);
(c) You continue to have a disabling impairment;
(d) If your disability is based on a determination that drug
addiction or alcoholism is a contributing factor material to the
determination of disability as described in Sec.416.935, you have not
yet received SSI cash benefits, special SSI cash benefits, or special
SSI eligibility status for a total of 36 months, or Social Security
benefit payments when treatment was available for a total of 36 months;
and
(e) You meet all the nondisability requirements for eligibility for
SSI benefits (see Sec.416.202).
We will follow the rules in this subpart in determining your eligibility
for special SSI cash benefits.
[47 FR 15324, Apr. 9, 1982, as amended at 59 FR 41404, Aug. 12, 1994; 60
FR 8149, Feb. 10, 1995; 64 FR 31972, June 15, 1999]
Sec.416.263 No additional application needed.
We do not require you to apply for special cash benefits nor is it
necessary for you to apply to have the special SSI eligibility status
determined. We will make these determinations automatically.
[47 FR 15324, Apr. 9, 1982]
Sec.416.264 When does the special SSI eligibility status apply.
The special SSI eligibility status applies for the purposes of
establishing or maintaining your eligibility for Medicaid. For these
purposes we continue to consider you to be a blind or disabled
individual receiving benefits even though you are in fact no longer
receiving regular SSI benefits or special SSI cash benefits. You must
meet the eligibility requirements in Sec.416.265 in order to qualify
for the special SSI eligibility status. Special SSI eligibility status
also applies for purposes of reacquiring status as eligible for regular
SSI benefits or special SSI cash benefits.
[59 FR 41404, Aug. 12, 1994]
Sec.416.265 Requirements for the special SSI eligibility status.
In order to be eligible for the special SSI eligibility status, you
must have been eligible to receive a regular SSI
[[Page 844]]
benefit or a federally administered State supplementary payment (see
Sec.416.2001) in a month before the month for which we are making the
special SSI eligibility status determination. The month you were
eligible for a regular SSI benefit or a federally administered State
supplementary payment may not be in a prior period of eligibility which
has been terminated according to Sec.Sec.416.1331 through 416.1335.
For periods prior to May 1, 1991, you must be under age 65. Also, we
must establish that:
(a) You are blind or you continue to have a disabling impairment
which, if drug addiction or alcoholism is a contributing factor material
to the determination of disability as described in Sec.416.935, has
not resulted in your receiving SSI cash benefits, special SSI cash
benefits, or special SSI eligibility status for a total of 36 months, or
Social Security benefit payments when treatment was available for a
total of 36 months;
(b) Except for your earnings, you meet all the nondisability
requirements for eligibility for SSI benefits (see Sec.416.202);
(c) The termination of your eligibility for Medicaid would seriously
inhibit your ability to continue working (see Sec.416.268); and
(d) Your earnings after the exclusions in Sec.416.1112(c) (6),
(8), and (9) are not sufficient to allow you to provide yourself with a
reasonable equivalent of the benefits (SSI benefits, federally
administered State supplementary payments, Medicaid, and publicly-funded
attendant care services, including personal care assistance under Sec.
416.269(d)) which would be available to you if you did not have those
earnings (see Sec.416.269).
[47 FR 15324, Apr. 9, 1982, as amended at 59 FR 41404, Aug. 12, 1994; 59
FR 49291, Sept. 27, 1994; 60 FR 8149, Feb. 10, 1995]
Sec.416.266 Continuation of SSI status for Medicaid
If we stop your benefits because of your earnings and you are
potentially eligible for the special SSI eligibility status you will
continue to be considered an SSI recipient for purposes of eligibility
for Medicaid during the time it takes us to determine whether the
special eligibility status applies to you.
[47 FR 15324, Apr. 9, 1982]
Sec.416.267 General.
We determine whether the special SSI eligibility status applies to
you by verifying that you continue to be blind or have a disabling
impairment by applying the rules in subpart I of this part, and by
following the rules in this subpart to determine whether you meet the
requirements in Sec.416.265(b). If you do not meet these requirements
we determine that the special eligibility status does not apply. If you
meet these requirements, then we apply special rules to determine if you
meet the requirements of Sec.416.265 (c) and (d). If for the period
being evaluated, you meet all of the requirements in Sec.416.265 we
determine that the special status applies to you.
[47 FR 15324, Apr. 9, 1982]
Sec.416.268 What is done to determine if you must have Medicaid in
order to work.
For us to determine that you need Medicaid benefits in order to
continue to work, you must establish:
(a) That you are currently using or have received services which
were paid for by Medicaid during the period which began 12 months before
our first contact with you to discuss this use; or
(b) That you expect to use these services within the next 12 months;
or
(c) That you would need Medicaid to pay for unexpected medical
expenses in the next 12 months.
[59 FR 41404, Aug. 12, 1994]
Sec.416.269 What is done to determine whether your earnings are too
low to provide comparable benefits and services you would receive in
the absence of those earnings.
(a) What we determine. We must determine whether your earnings are
too low to provide you with benefits and services comparable to the
benefits and services you would receive if you did not have those
earnings (see Sec.416.265(d)).
(b) How the determination is made. In determining whether your
earnings are too low to provide you with benefits
[[Page 845]]
and services comparable to the benefits and services you would receive
if you did not have those earnings, we compare your anticipated gross
earnings (or a combination of anticipated and actual gross earnings, as
appropriate) for the 12-month period beginning with the month for which
your special SSI eligibility status is being determined to a threshold
amount for your State of residence. This threshold amount consists of
the sum for a 12-month period of two items, as follows:
(1) The amount of gross earnings including amounts excluded under
Sec.416.1112(c) (4), (5) and (7) that would reduce to zero the Federal
SSI benefit and the optional State supplementary payment for an
individual with no other income living in his or her own household in
the State where you reside. This amount will vary from State to State
depending on the amount of the State supplementary payment; and
(2) The average expenditures for Medicaid benefits for disabled and
blind SSI cash recipients, including recipients of federally
administered State supplementary payments only, in your State of
residence.
(c) How the eligibility requirements are met. (1) You meet the
requirements in Sec.416.265(d) if the comparison shows that your gross
earnings are equal to or less than the applicable threshold amount for
your State, as determined under paragraphs (b) (1) and (2) of this
section. However, if the comparison shows that these earnings exceed the
applicable threshold amount for your State, we will establish (and use
in a second comparison) an individualized threshold taking into account
the total amount of:
(i) The amount determined under paragraph (b)(1) of this section
that would reduce to zero the Federal SSI benefit and State
supplementary payment for your actual living arrangement;
(ii) The average Medicaid expenditures for your State of residence
under paragraph (b)(2) of this section or, if higher, your actual
medical expenditures in the appropriate 12-month period;
(iii) Any amounts excluded from your income as impairment-related
work expenses (see Sec.416.1112(c)(6)), work expenses of the blind
(see Sec.416.1112(c)(8)), and income used or set aside for use under
an approved plan for achieving self support (see Sec.416.1112(c)(9));
and
(iv) the value of any publicly-funded attendant care services as
described in paragraph (d) of this section (including personal care
assistance).
(2) If you have already completed the 12-month period for which we
are determining your eligibility, we will consider only the expenditures
made in that period.
(d) Attendant care services. Expenditures for attendant care
services (including personal care assistance) which would be available
to you in the absence of earnings that make you ineligible for SSI cash
benefits will be considered in the individualized threshold (as
described in paragraph (c)(1) of this section) if we establish that they
are:
(1) Provided by a paid attendant;
(2) Needed to assist with work-related and/or personal functions;
and
(3) Paid from Federal, State, or local funds.
(e) Annual update of information. The threshold amounts used in
determinations of sufficiency of earnings will be based on information
and data updated no less frequently than annually.
[59 FR 41404, Aug. 12, 1994; 59 FR 49291, Sept. 27, 1994]
Subpart C_Filing of Applications
Authority: Secs. 702(a)(5), 1611, and 1631 (a), (d), and (e) of the
Social Security Act (42 U.S.C. 902(a)(5), 1382, and 1383 (a), (d), and
(e)).
Source: 45 FR 48120, July 18, 1980, unless otherwise noted.
General Provisions
Sec.416.301 Introduction.
This subpart contains the rules for filing a claim for supplemental
security income (SSI) benefits. It tells you what an application is, who
may sign it, who must file one to be eligible for benefits, the period
of time it is in effect, and how it may be withdrawn. It also tells you
when a written statement or an oral inquiry may be considered to
establish an application filing date.
[[Page 846]]
Sec.416.302 Definitions.
For the purpose of this subpart--
Benefits means any payments made under the SSI program. SSI benefits
also include any federally administered State supplementary payments.
Claimant means the person who files an application for himself or
herself or the person on whose behalf an application is filed.
We or us means the Social Security Administration (SSA).
You or your means the person who applies for benefits, the person
for whom an application is filed or anyone who may consider applying for
benefits.
Sec.416.305 You must file an application to receive supplemental
security income benefits.
(a) General rule. In addition to meeting other requirements, you
must file an application to become eligible to receive benefits. If you
believe you may be eligible, you should file an application as soon as
possible. Filing an application will--
(1) Permit us to make a formal determination whether or not you are
eligible to receive benefits;
(2) Assure that you receive benefits for any months you are eligible
to receive payment; and
(3) Give you the right to appeal if you disagree with the
determination.
(b) Exceptions. You need not file a new application if--
(1) You have been receiving benefits as an eligible spouse and are
no longer living with your husband or wife;
(2) You have been receiving benefits as an eligible spouse of an
eligible individual who has died;
(3) You have been receiving benefits because you are disabled or
blind and you are 65 years old before the date we determine that you are
no longer blind or disabled.
(4) A redetermination of your eligibility is being made and it is
found that you were not eligible for benefits during any part of a
period for which we are making a redetermination but you currently meet
the requirements for eligibility;
(5) You are notified that your payments of SSI benefits will be
stopped because you are no longer eligible and you again meet the
requirements for eligibility before your appeal rights are exhausted.
[45 FR 48120, July 18, 1980, as amended at 60 FR 16374, Mar. 30, 1995;
64 FR 31972, June 15, 1999]
Applications
Sec.416.310 What makes an application a claim for benefits.
An application will be considered a claim for benefits, if the
following requirements are met:
(a) An application form prescribed by us must be filled out.
(b) be filed at a social security office, at another Federal or
State office we have designated to receive applications for us, or with
a person we have authorized to receive applications for us. See Sec.
416.325.
(c) The claimant or someone who may sign an application for the
claimant must sign the application. See Sec.Sec.416.315 and 416.320.
(d) The claimant must be alive at the time the application is filed.
See Sec.Sec.416.340, 416.345, and 416.351 for exceptions.
[45 FR 48120, July 18, 1980, as amended at 59 FR 44926, Aug. 31, 1994]
Sec.416.315 Who may sign an application.
We will determine who may sign an application according to the
following rules:
(a) If you are 18 years old or over, mentally competent, and
physically able, you must sign your own application. If you are 16 years
old or older and under age 18, you may sign the application if you are
mentally competent, have no court appointed representative, and are not
in the care of any other person or institution.
(b) If the claimant is under age 18, or is mentally incompetent, or
is physically unable to sign the application, a court appointed
representative or a person who is responsible for the care of the
claimant, including a relative, may sign the application. If the
claimant is in the care of an institution, the manager or principal
officer of the institution may sign the application.
(c) To prevent a claimant from losing benefits because of a delay in
filing an application when there is a good reason
[[Page 847]]
why the claimant cannot sign an application, we may accept an
application signed by someone other than a person described in this
section.
Example: Mr. Smith comes to a Social Security office to file an
application for SSI disability benefits for Mr. Jones. Mr. Jones, who
lives alone, just suffered a heart attack and is in the hospital. He
asked Mr. Smith, whose only relationship is that of a neighbor and
friend, to file the application for him. We will accept an application
signed by Mr. Smith since it would not be possible to have Mr. Jones
sign and file the application at this time. SSI benefits can be paid
starting with the first day of the month following the month the
individual first meets all eligibility requirements for such benefits,
including having filed an application. If Mr. Smith could not sign an
application for Mr. Jones, a loss of benefits would result if it is
later determined that Mr. Jones is in fact disabled.
[45 FR 48120, July 18, 1980, as amended at 51 FR 13492, Apr. 21, 1986;
64 FR 31972, June 15, 1999]
Sec.416.320 Evidence of authority to sign an application for another.
(a) A person who signs an application for someone else will be
required to provide evidence of his or her authority to sign the
application for the person claiming benefits under the following rules:
(1) If the person who signs is a court appointed representative, he
or she must submit a certificate issued by the court showing authority
to act for the claimant.
(2) If the person who signs is not a court appointed representative,
he or she must submit a statement describing his or her relationship to
the claimant. The statement must also describe the extent to which the
person is responsible for the care of the claimant. This latter
information will not be requested if the application is signed by a
parent for a child with whom he or she is living. If the person signing
is the manager or principal officer of an institution he or she should
show his or her title.
(b) We may, at any time, require additional evidence to establish
the authority of a person to sign an application for someone else.
[45 FR 48120, July 18, 1980, as amended at 51 FR 13493, Apr. 21, 1986]
Sec.416.325 When an application is considered filed.
(a) General rule. We consider an application for SSI benefits filed
on the day it is received by an employee at any social security office,
by someone at another Federal or State office designated to receive
applications for us, or by a person we have authorized to receive
applications for us.
(b) Exceptions. (1) When we receive an application that is mailed,
we will use the date shown by the United States postmark as the filing
date if using the date the application is received will result in a loss
of benefits. If the postmark is unreadable or there is no postmark, we
will use the date the application is signed (if dated) or 5 days before
the day we receive the signed application, whichever date is later.