2189. Initial Determinations

2189.1 What is an "initial determination"?

An "initial determination" is the first decision made on an application, post-eligibility event, or a periodic redetermination of eligibility. An initial determination generally involves eligibility for, or the amount of, SSI payments (including federally administered State supplementary payments). See §2002.1.

2189.2 What should you do if you are not satisfied with SSA's initial determination?

We offer several independent reviews of your case if you are dissatisfied with our determination. Each review is a step in the administrative appeals process. You must request review within specified time limits. If you do not request the next step within the time limit, our decision becomes final and binding on the parties affected (except for determinations/decisions reopened under the rules of administrative finality (see §2197)). We may extend the time limit for good cause.

2189.3 What matters can you appeal?

Your legal right to appeal flows from findings that are initial determinations. You do not have the legal right to appeal matters that are not the subject of an initial determination. However, we may, at our discretion, review, reopen, and revise our initial (or appellate) determination.

2189.4 What are examples of initial determinations?

The following are examples of initial determinations:

1. Eligibility as an aged, blind, or disabled individual;

2. Eligibility for and the amount of an SSI payment;

3. Eligibility for and the amount of an SSA (or Federally) administered State supplementary payment;

4. Eligibility for and the amount of payment to an eligible recipient who has an essential person living in the home;

5. Residency, citizenship, or alien status;

6. Amount of income and what constitutes income and exclusions from income for a period. However, there are no appeal rights on findings based on income estimates for a future period. Any changes of income estimates are disposed of as redeterminations;

7. Amount of resources, what constitutes resources for a period, allocation of resources, tests of ownership, determination of value, exclusion from resources, and disposition of resources;

8. Marital relationship of an individual and spouse for SSI purposes;

9. Living arrangements for SSI purposes;

10. Failure to file for and/or pursue benefits under other programs;

11. Status as a child;

12. Status as a resident of a public institution;

13. Status as a drug addict or alcoholic and compliance with the terms, conditions, and requirements of treatment deemed appropriate for those conditions;

14. Status as a patient, through any month, in a medical treatment facility receiving payments under Title XIX (Grants to States for Medical Assistance Programs) of the Social Security Act;

15. Ineligibility for benefits because of refusal, without good cause, to accept available vocational rehabilitation services for the blind and disabled;

16. Imposition of a penalty deduction for failure, without good cause, to report, or to report timely, any change in circumstances or events that would affect eligibility and/or payment amount;

17. Reduction, suspension, or termination of payments;

18. Reinstatement of payments, as well as denial of reinstatement, when the individual has requested reinstatement in writing;

19. Fact and amount of underpayment or overpayment;

20. Waiver of recovery of overpayment;

21. Need for a representative payee (except for a recipient under age 18, a person adjudged legally incompetent or a drug addict or alcoholic), the selection of a payee, that a designated payee will no longer serve, or suspension of payments for lack of a suitable payee. In cases of drug addiction and alcoholism, payment through a representative payee is mandatory and this is not an initial determination with administrative appeal rights. However, a legally competent drug addict or alcoholic may appeal the determination that a particular person should serve as representative payee. Only the recipient, the recipient's representative, or an essential person can appeal a decision on the selection of a representative payee;

22. Decisions of ineligibility for failure to submit evidence;

23. Denial of a request for withdrawal of an application, or the denial of a request for cancellation of a withdrawal request;

24. Deemed redeterminations (i.e., the redetermination of eligibility that is presumed to have taken place on the first day of any month for which eligibility and payment amount do not change, but only for the purposes of administrative finality); and

25. Decision to recover an overpayment, including through 10 percent check adjustment.

Last Revised: Jun. 22, 2004