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We are clarifying our rules regarding the redetermination of the entitlement or eligibility of individuals when there is reason to believe fraud or similar fault was involved in the individual’s application for benefits. We intend to clarify how and when we redetermine the entitlement, and the administrative review process when we decide to terminate benefits.

Statement of Need:

Over time, our business processes evolved to support our statutory redetermination authority. We are now codifying the basic parameters for redetermination, including relevant definitions, clarification of notice and redetermination procedures, as well as a process for administratively reviewing redetermination termination and overpayment assessment decisions under secs. 205(u) and 1631(e)(7) of the Social Security Act, to provide the public the opportunity for comment under the Administrative Procedures Act while providing our beneficiaries and their representatives the ability to find our redetermination process within our regulatory text.

Summary of the Legal Basis:

Sections 205(u), 1129(l), and 1631(e)(7) of the Social Security Act. 42 U.S.C. 405(u)(1), 1320a-8(l), and 1383(e)(7).

206(d) of Pub. L. No. 103-296, the Social Security Independence and Program Improvements Act of 1994, 108 Stat. 1464, 1509.

Alternatives:

We could continue to manage our redetermination processes and procedures under our statutory authority and sub-regulatory guidances.

Anticipated Costs and Benefits:

Without enumerated regulations, we may experience additional litigation alleging lack of due process and violation of the Administrative Procedures Act.

Risks:

Without enumerated regulations, we may experience litigation alleging lack of due process and violation of the Administrative Procedures Act.