Title 20, Part 416 — Supplemental Security Income for the Aged, Blind, and Disabled

Introduction.

Administration.

Purpose of program.

General definitions and use of terms.

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.

Introduction.

General definitions and terms used in this subpart.

Who may get SSI benefits.

Initial determinations of SSI eligibility.

Redeterminations of SSI eligibility.

You do not give us permission to contact financial institutions.

You do not apply for other benefits.

You are a resident of a public institution.

Continuation of full benefits in certain cases of medical confinement.

You are disabled and drug addiction or alcoholism is a contributing factor material to the determination of disability.

You leave the United States.

You are a child of armed forces personnel living overseas.

General.

Who is a qualified individual.

Who is an essential person.

What happens if you are a qualified individual.

Experimental, pilot, and demonstration projects in the SSI program.

General.

What are special SSI cash benefits and when are they payable.

Eligibility requirements for special SSI cash benefits.

No additional application needed.

When does the special SSI eligibility status apply.

Requirements for the special SSI eligibility status.

Continuation of SSI status for Medicaid

General.

What is done to determine if you must have Medicaid in order to work.

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.

Introduction.

Definitions.

You must file an application to receive supplemental security income benefits.

What makes an application a claim for benefits.

Who may sign an application.

Evidence of authority to sign an application for another.

When an application is considered filed.

Pilot program for photographic identification of disability benefit applicants in designated geographic areas.

Filing before the first month you meet the requirements for eligibility.

Filing in or after the month you meet the requirements for eligibility.

Use of date of written statement as application filing date.

Use of date of oral inquiry as application filing date.

Treating a title II application as an oral inquiry about SSI benefits.

Deemed filing date in a case of misinformation.

Withdrawal of an application.

Cancellation of a request to withdraw.

Scope of subpart.

Cost-of-living adjustments in benefits.

Amount of benefits; eligible individual.

Amount of benefits; eligible couple.

Amount of benefits; qualified individual.

Amount of benefits; eligible individual or eligible couple in a medical treatment facility.

Amount of benefits; eligible individual is disabled child under age 18.

Determination of benefits; general.

Determination of benefits; computation of prorated benefits.

Change in status involving an individual; ineligibility occurs.

Eligible individual without an eligible spouse has an essential person in his home.

Eligible individual with eligible spouse; essential person(s) present.

Change in status involving a couple; eligibility continues.

Change in status involving a couple; ineligibility occurs.

Payment of benefits: General.

Manner of payment.

Minimum monthly benefit amount.

Emergency advance payments.

Reimbursement to States for interim assistance payments.

Method of payment when the essential person resides with more than one eligible person.

Transfer or assignment of benefits.

Garnishment of payments after disbursement.

Underpayments and overpayments.

Underpayments—defined.

Overpayments—defined.

Amount of underpayment or overpayment.

Underpayments—to whom underpaid amount is payable.

Underpayments—applied to reduce overpayments.

Paying benefits in installments: Drug addiction or alcoholism.

Paying large past-due benefits in installments.

Payment into dedicated accounts of past-due benefits for eligible individuals under age 18 who have a representative payee.

Waiver of adjustment or recovery—when applicable.

Waiver of adjustment or recovery—effect of.

Waiver of adjustment or recovery—without fault.

Waiver of adjustment or recovery—defeat the purpose of the supplemental security income program.

Waiver of adjustment or recovery—against equity and good conscience.

Waiver of adjustment or recovery—impede administration.

Waiver of adjustment or recovery—countable resources in excess of the limits prescribed in § 416.1205 by $50 or less.

Personal conference.

Notice relating to overpayments and underpayments.

Recovery—refund.

Adjustment.

10-percent limitation of recoupment rate—overpayment.

Are title II and title VIII benefits subject to adjustment to recover title XVI overpayments?

How much will we withhold from your title II and title VIII benefits to recover a title XVI overpayment?

Will you receive notice of our intention to apply cross-program recovery?

When will we begin cross-program recovery from your current monthly benefits?

Referral of overpayments to the Department of the Treasury for tax refund offset—General.

Notice to overpaid person.

Review within SSA that an overpayment is past due and legally enforceable.

Findings by SSA.

Review of our records related to the overpayment.

Suspension of offset.

Tax refund insufficient to cover amount of overpayment.

Are there additional methods for recovery of title XVI benefit overpayments?

Introduction.

When payment will be made to a representative payee.

What happens to your monthly benefits while we are finding a suitable representative payee for you?

Information considered in determining whether to make representative payment.

Advance designation of representative payees.

Information considered in selecting a representative payee.

What is our order of preference in selecting a representative payee for you?

Who may not serve as a representative payee?

How do we investigate a representative payee applicant?

What information must a representative payee report to us?

How do we investigate an appointed representative payee?

How will we notify you when we decide you need a representative payee?

What are the responsibilities of your representative payee?

Use of benefit payments.

Compensation for qualified organizations serving as representative payees.

Who is liable if your representative payee misuses your benefits?

Conservation and investment of benefit payments.

When will we select a new representative payee for you?

When representative payment will be stopped.

Transfer of accumulated benefit payments.

How does your representative payee account for the use of benefits?

Scope of subpart.

Definitions.

Who must make reports.

What you must report.

Reduced reporting requirements when you authorize us to obtain your information from payroll data providers.

What reports must include.

Form of the report.

When reports are due.

Circumstances under which we make a penalty deduction.

Amounts of penalty deductions.

Penalty period: First failure to report.

Penalty period: Second failure to report.

Penalty period: Three or more failures to report.

No penalty deduction if you have good cause for failure to report timely.

Evidence as to age—when required.

Type of evidence to be submitted.

Evaluation of evidence.

Certified copy in lieu of original.

When additional evidence may be required.

Expedited adjudication based on documentary evidence of age.

Scope of subpart.

Definitions for this subpart.

Who makes disability and blindness determinations.

Program integrity.

Evidence from excluded medical sources of evidence.

Decisions by other governmental agencies and nongovernmental entities.

Basic definition of disability for adults.

Basic definition of disability for children.

Disability under a State plan.

[Reserved]

How long the impairment must last.

Meaning of substantial gainful activity.

Definition of disabling impairment.

Responsibility for evidence.

Categories of evidence.

Evidence from our Federal or State agency medical or psychological consultants.

When we will purchase existing evidence.

Where and how to submit evidence.

If you fail to submit medical and other evidence.

Consultative examination at our expense.

If you do not appear at a consultative examination.

The consultative examination.

When we will purchase a consultative examination and how we will use it.

When we will not purchase a consultative examination.

Type of purchased examinations.

Who we will select to perform a consultative examination.

Your medical source.

Other sources for consultative examinations.

Objections to the medical source designated to perform the consultative examination.

Purchase of medical examinations, laboratory tests, and other services.

Diagnostic tests or procedures.

Informing the medical source of examination scheduling, report content, and signature requirements.

When a properly signed consultative examination report has not been received.

Reviewing reports of consultative examinations.

Conflict of interest.

Authorizing and monitoring the consultative examination.

Consultative examination oversight.

Evaluation of disability of adults, in general.

Evaluation of mental impairments.

How we consider evidence.

How we consider and articulate medical opinions and prior administrative medical findings for claims filed on or after March 27, 2017.

Establishing that you have a medically determinable impairment(s).

What we mean by an impairment(s) that is not severe in an adult.

Multiple impairments.

How we determine disability for children.

Considerations in determining disability for children.

Age as a factor of evaluation in the sequential evaluation process for children.

Listing of Impairments in appendix 1 of subpart P of part 404 of this chapter.

Medical equivalence for adults and children.

Functional equivalence for children.

Evaluating opinion evidence for claims filed before March 27, 2017.

[Reserved]

How we evaluate symptoms, including pain.

Need to follow prescribed treatment.

The meaning of presumptive disability or presumptive blindness.

When presumptive payments begin and end.

How we make a finding of presumptive disability or presumptive blindness.

Impairments that may warrant a finding of presumptive disability or presumptive blindness.

How we will determine whether your drug addiction or alcoholism is a contributing factor material to the determination of disability.

Treatment required for individuals whose drug addiction or alcoholism is a contributing factor material to the determination of disability.

What we mean by appropriate treatment.

What we mean by approved institutions or facilities.

How we consider whether treatment is available.

Evaluating compliance with the treatment requirements.

Establishment and use of referral and monitoring agencies.

Your residual functional capacity.

Responsibility for assessing your residual functional capacity.

When we will consider your vocational background.

Medical-vocational profiles showing an inability to make an adjustment to other work.

Your age as a vocational factor.

Your education as a vocational factor.

Your work experience as a vocational factor.

Work which exists in the national economy.

Physical exertion requirements.

Skill requirements.

Listing of Medical-Vocational Guidelines in appendix 2 of subpart P of part 404 of this chapter.

Exertional and nonexertional limitations.

General.

What we mean by substantial gainful activity.

General information about work activity.

Evaluation guides if you are an employee.

When and how we will average your earnings.

Evaluation guides if you are self-employed.

Impairment-related work expenses.

Meaning of blindness as defined in the law.

Blindness under a State plan.

How we evaluate statutory blindness.

If you are statutorily blind and still working.

How we evaluate other visual impairments.

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.

Your responsibility to tell us of events that may change your disability or blindness status.

We may conduct a review to find out whether you continue to be disabled.

We may conduct a review to find out whether you continue to be blind.

When and how often we will conduct a continuing disability review.

If your medical recovery was expected and you returned to work.

What happens if you fail to comply with our request for information.

[Reserved]

Medical evidence in continuing disability review cases.

How we will determine whether your disability continues or ends, disabled adults.

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.

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).

Continued disability or blindness benefits pending appeal of a medical cessation determination.

If you become disabled by another impairment(s).

What is expedited reinstatement?

Who is eligible for expedited reinstatement?

How do I request reinstatement?

How do we determine provisional benefits?

How do we determine reinstated benefits?

Purpose and scope.

Definitions.

Basic responsibilities for us and the State.

How a State notifies us that it wishes to perform the disability determination function.

How we notify a State whether it may perform the disability determination function.

Disability determinations the State makes.

Responsibilities for obtaining evidence to make disability determinations.

Making disability determinations.

Medical consultants and psychological consultants.

Reasonable efforts to obtain review by a physician, psychiatrist, and psychologist.

Notifying claimant of the disability determination.

Quick disability determination process.

General administrative requirements.

Personnel.

Training.

Facilities.

Medical and other purchased services.

Records and reports.

Fiscal.

Audits.

Property.

Participation in research and demonstration projects.

Coordination with other agencies.

Confidentiality of information and records.

Other Federal laws and regulations.

Policies and operating instructions.

General.

Standards of performance.

Processing time standards.

Performance accuracy standard.

How and when we determine whether the processing time standards are met.

How and when we determine whether the performance accuracy standard is met.

Action we will take if a State agency does not meet the standards.

How we will monitor.

When we will provide performance support.

What support we will provide.

General.

Good cause for not following the Act, our regulations, or other written guidelines.

Finding of substantial failure.

Notice of right to hearing on proposed finding of substantial failure.

Disputes on matters other than substantial failure.

Who conducts the hearings.

Hearings and appeals process.

Assumption when we make a finding of substantial failure.

Assumption when State no longer wishes to perform the disability determination function.

Protection of State employees.

Limitation on State expenditures after notice.

Final accounting by the State.

Income and SSI eligibility.

Definition of terms.

What is income?

What is not income?

Income we count.

What is earned income.

How we count earned income.

Earned income we do not count.

What is unearned income.

Types of unearned income.

How we count unearned income.

Unearned income we do not count.

Introduction.

The one-third reduction rule.

What we mean by “living in another person's household”.

What is a pro rata share of household operating expenses.

The presumed value rule.

When the presumed value rule applies.

If you live in a public assistance household.

If you live in a noninstitutional care situation.

If you live in a nonprofit retirement home or similar institution.

How the presumed value rule applies in a nonmedical for-profit institution.

How we value in-kind support and maintenance for a couple.

Income rules in change-of-status situations involving in-kind support and maintenance.

If you have both in-kind support and maintenance and income that is deemed to you.

What is a temporary absence from your living arrangement.

How we treat income received because of a major disaster.

How we treat the repair or replacement of lost, damaged, or stolen resources.

Support and maintenance assistance.

What is deeming of income?

Income of an ineligible spouse, ineligible parent, and essential person for deeming purposes.

Income for deeming purposes where Medicaid eligibility is affected.

How we deem income to you from your ineligible spouse.

How we deem income to you from your ineligible parent(s).

How we deem income to you and your eligible child from your ineligible spouse.

How we deem income to you from your sponsor if you are an alien.

Temporary absences and deeming rules.

How we deem income to you from your essential person.

When we stop deeming income from an essential person.

General.

When the alternative rules apply.

General.

What is a plan to achieve self-support (PASS)?

When we begin to count the income excluded under the plan.

Resources; general.

Deeming of resources.

Deeming of resources of an essential person.

Deeming of resources of the sponsor of an alien.

Deeming of resources where Medicaid eligibility is affected.

Limitation on resources.

Resources determinations.

How funds held in financial institution accounts are counted.

Exclusions from resources; general.

Exclusion of the home.

Exclusion of household goods and personal effects.

Exclusion of the automobile.

Property essential to self-support; general.

How income-producing property essential to self-support is counted.

How nonbusiness property used to produce goods or services essential to self-support is counted.

An approved plan to achieve self-support; general.

What is a plan to achieve self-support (PASS)?

When the resources excluded under a plan to achieve self-support begin to count.

Exclusion of Alaskan natives' stock in regional or village corporations.

Exclusion of payments received as compensation for expenses incurred or losses suffered as a result of a crime.

Exclusion of life insurance.

Burial spaces and certain funds set aside for burial expenses.

Replacement of lost, damaged, or stolen excluded resources.

Exclusion of certain underpayments from resources.

Exclusion of Indian lands.

Exclusion of certain payments related to tax credits.

Exclusions from resources; provided by other statutes.

Assistance received on account of major disaster.

Exclusion of certain housing assistance.

Exclusion of State or local relocation assistance payments.

Disposition of resources.

Time limits for disposing of resources.

Treatment of proceeds from disposition of resources.

Exceptions to required disposition of real property.

Disposal of resources at less than fair market value.

Exclusion of a dedicated account in a financial institution.

Exclusion of gifts to children with life-threatening conditions.

Exclusion of payments received as restitution for misuse of benefits by a representative payee.

How we count grants, scholarships, fellowships or gifts.

Special resource provision for recipients under a State plan.

Application of special resource provision.

Special resource provision applicable in cases involving essential persons.

Spouse ineligible under a State plan in December 1973.

Individual under special resource provision dies after December 1973.

Suspensions; general.

Suspension for not giving us permission to contact financial institutions.

Suspension due to failure to comply with request for information.

Suspension due to excess income.

Suspension due to excess resources.

Suspension due to status as a resident of a public institution.

Suspension for failure to comply with treatment for drug addiction or alcoholism.

Suspension due to absence from the United States.

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.

Suspension due to failure to apply for and obtain other benefits.

Termination of your disability or blindness payments.

Termination of benefit for disabled individual: Exception.

Termination at the request of the recipient.

Termination due to death of recipient.

Termination due to continuous suspension.

Notice of intended action affecting recipient's payment status.

Exceptions to the continuation of previously established payment level.

If you are participating in an appropriate program of vocational rehabilitation services, employment services, or other support services.

Suspension due to flight to avoid criminal prosecution or custody or confinement after conviction, or due to violation of probation or parole.

Penalty for making false or misleading statements or withholding information.

Introduction.

Definitions.

Administrative actions that are initial determinations.

Administrative actions that are not initial determinations.

Notice of the initial determination.

Effect of an initial determination.

Testing modifications to the disability determination procedures.

Reconsideration—general.

Parties to a reconsideration.

How to request reconsideration.

Good cause for missing the deadline to request review.

Reconsideration procedures.

Reconsiderations of initial determinations on applications.

Reconsideration procedures for post-eligibility claims.

Arrangement for conferences.

Disability hearing—general.

Disability hearing—disability hearing officers.

Disability hearing—procedures.

Disability hearing—disability hearing officer's reconsidered determination.

Disability hearing—review of the disability hearing officer's reconsidered determination before it is issued.

Notice of another person's request for reconsideration.

Reconsidered determination.

Effect of a reconsidered determination.

Notice of a reconsidered determination.

Expedited appeals process—general.

When the expedited appeals process may be used.

How to request expedited appeals process.

Agreement in expedited appeals process.

Effect of expedited appeals process agreement.

Expedited appeals process request that does not result in agreement.

Hearing before an administrative law judge—general.

Availability of a hearing before an administrative law judge.

Parties to a hearing before an administrative law judge.

How to request a hearing before an administrative law judge.

Submitting written evidence to an administrative law judge.

Time, place, and manner of appearance for a hearing before an administrative law judge.

Protecting the safety of the public and our employees in our hearing process.

Notice of a hearing before an administrative law judge.

Objections to the issues.

Disqualification of the administrative law judge.

Prehearing case review.

Prehearing proceedings and decisions by attorney advisors.

Responsibilities of the adjudication officer.

Administrative law judge hearing procedures—general.

Issues before an administrative law judge.

Deciding a case without an oral hearing before an administrative law judge.

Presenting written statements and oral arguments.

Presenting evidence at a hearing before an administrative law judge.

Official record.

Consolidated hearings before an administrative law judge.

The decision of an administrative law judge.

The effect of a hearing decision.

Removal of a hearing request(s) to the Appeals Council.

Dismissal of a request for a hearing before an administrative law judge.

Notice of dismissal of a request for a hearing before an administrative law judge.

Effect of dismissal of a request for a hearing before an administrative law judge.

Vacating a dismissal of a request for a hearing before an administrative law judge.

Prehearing and posthearing conferences.

[Reserved]

[Reserved]

Appeals Council review—general.

How to request Appeals Council review.

Appeals Council initiates review.

Cases the Appeals Council will review.

Dismissal by Appeals Council.

Effect of dismissal of request for Appeals Council review.

Notice of Appeals Council review.

Obtaining evidence from Appeals Council.

Filing briefs with the Appeals Council.

Procedures before the Appeals Council.

Case remanded by Appeals Council.

Decision of Appeals Council.

Effect of Appeals Council's decision or denial of review.

Extension of time to file action in Federal district court.

Case remanded by a Federal court.

Appeals Council review of hearing decision in a case remanded by a Federal court.

Application of circuit court law.

Reopening and revising determinations and decisions.

Conditions for reopening.

Good cause for reopening.

Late completion of timely investigation.

Notice of revised determination or decision.

Effect of revised determination or decision.

Time and place to request further review or a hearing on revised determination or decision.

Payment of certain travel expenses—general.

Who may be reimbursed.

What travel expenses are reimbursable.

When and how to claim reimbursement.

Introduction.

Definitions.

Who may be your representative.

Notification of options for obtaining attorney representation.

Appointing a representative.

Authority of a representative.

Mandatory use of electronic services.

Notice or request to a representative.

Direct payment of fees to eligible non-attorney representatives.

Fee for a representative's services.

Request for approval of a fee.

Proceedings before a State or Federal court.

Payment of fees.

Entity eligible for direct payment of fees.

Rules of conduct and standards of responsibility for representatives.

Violations of our requirements, rules, or standards.

Notice of charges against a representative.

Withdrawing charges against a representative.

Hearing on charges.

Decision by hearing officer.

Requesting review of the hearing officer's decision.

Assignment of request for review of the hearing officer's decision.

Appeals Council's review of hearing officer's decision.

Evidence permitted on review.

Appeals Council's decision.

When the Appeals Council will dismiss a request for review.

Reinstatement after suspension—period of suspension expired.

Reinstatement after suspension or disqualification—period of suspension not expired.

Introduction.

Definitions and terms used in this subpart.

How to prove you are a resident of the United States.

How to prove you are a citizen or a national of the United States.

How to prove you are lawfully admitted for permanent residence in the United States.

When you are considered permanently residing in the United States under color of law.

When you cannot be considered permanently residing in the United States under color of law.

Scope of subpart.

Definitions.

Whom we refer and when.

Whom we refer.

Effect of your failure to comply with treatment requirements for your drug addiction or alcoholism.

Introduction.

Effects of marriage on eligibility and amount of benefits.

Whether you are married and who is your spouse.

Information we need concerning marriage when you apply for SSI.

Showing that you are married when you apply for SSI.

Showing that you are not married when you apply for SSI.

When we stop considering you and your spouse an eligible couple.

When we consider your marriage ended.

Information we need about separation or end of marriage after you become eligible for SSI.

Effects of being considered a child.

Who is considered a child.

Deciding whether you are a child: Are you a student?

Deciding whether you are a child: Are you the head of a household?

Effect of being considered a student.

Who is considered a student.

When we need evidence that you are a student.

Effects a parent (or parents) can have on the child's benefits.

Deciding whether someone is your parent or stepparent.

Scope of subpart S.

Definitions.

Authorization to withhold SSI benefits.

When your authorization is in effect.

When we need another authorization.

Requirements for interim assistance agreement.

Your appeal rights in the State.

Your appeal rights in SSA.

State supplementary payments; general.

Administration agreements with SSA.

Essentials of the administration agreements.

Establishing eligibility.

Federally administered supplementary payments.

Optional supplementation: Countable income.

Optional supplementation: Variations in payments.

Optional supplementation: Additional State options.

Limitations on eligibility.

Overpayments and underpayments; federally administered supplementation.

Waiver of State supplementary payments.

Mandatory minimum State supplementation.

Mandatory minimum supplementation reduced.

Mandatory minimum supplementary payments not applicable.

Mandatory minimum State supplementation: Agreement deemed.

Mandatory supplementation: State compliance not applicable.

Monitoring of mandatory minimum supplementary payments.

State funds transferred for supplementary payments.

Pass-along of Federal benefit increases.

Basic pass-along rules.

Combined supplementary/SSI payment levels.

Supplementary payment levels.

Compliance with pass-along.

Introduction.

Conditions for our agreeing to make Medicaid eligibility determinations.

Medicaid eligibility determinations.

Effect of the agreement and responsibilities of States.

Liability for erroneous Medicaid eligibility determinations.

Services other than Medicaid determinations.

Charges to States.

Changing the agreement.

Duration of agreement.

Disagreements between a State and us.

General.

Purpose and scope.

Definitions.

Participation by State VR agencies.

[Reserved]

Requirements for payment.

Responsibility for making payment decisions.

What we mean by “SGA” and by “a continuous period of 9 months”.

Criteria for determining when VR services will be considered to have contributed to a continuous period of 9 months.

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.

Services for which payment may be made.

When services must have been provided.

When claims for payment for VR services must be made (filing deadlines).

What costs will be paid.

[Reserved]

Method of payment.

Audits.

Validation reviews.

Confidentiality of information and records.

Other Federal laws and regulations.

Resolution of disputes.