Ssa-9301

Medicare Subsidy Quality Review Case Analysis, 20 CFR 418(b)(5)

SSA-9301

SSA-9301

OMB: 0960-0707

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FORM APPROVED

OMB No. 0960-0707

MEDICARE SUBSIDY - QUALITY REVIEW CASE ANALYSIS


1. QA Office Code: _________ Sample Cycle: ____________ Study ID: __________

Subsidy Level: _______% Interview date: ____________

2. Beneficiary’s (BN) SSN: ____________

Living-with Spouse’s SSN (If applicable): ____________

Type of Application: Beneficiary Only Beneficiary/Living-with Spouse

Date Application Filed: __________ Protective Filing Date/MOE: ___________

If death precluded interview, provide date of death & exclude: ____________

Other Exclusion (see remarks) Interview Incomplete (see remarks)

________________________________________________________________________



Name of BN: _______________________


Address: ___________________________ ___________________________

___________________________


Phone: ( ) ____________________


Living-with Spouse: Yes No


Name of Spouse: ____________________


Living-with Spouse contacted:


Yes No














Other Contact:


Representative Payee (if applicable)


Name: ________________________

Address: _______________________

_______________________

Phone: ( ) ______________


Third Party

Name: ________________________

Address: ________________________

________________________

Phone: ( ) ______________




SSA Records Interview

1. Identity

SSN:

Beneficiary:

_______________


Living-with Spouse:

_______________

Date of Birth


Beneficiary: __________________


Living-with Spouse:

__________________

__________________

2. Marital Status

Single, Divorced,

Widow(er),

Married Not

Living-with

Spouse


Married Living-

with Spouse


















SSN agrees with systems queries


Beneficiary Living-with Spouse


_________________ Name on Record ____________________

_________________ Date of Birth ____________________

_________________ Birthplace ____________________

_________________ Parents ____________________

_________________ ____________________







_________________________________________________________

What was your marital status at the time the application was filed?


Single, Divorced, Widow(er), Married Not Living-with Spouse


Married Living-with Spouse


Has there been any change in marital status since the application date?


Yes No


If yes, indicate type of change below.


Divorce Separation from Spouse

Annulment Death of your Spouse

Marriage Resumption of cohabitation

after separation


Date of change: __________________




Verification Conclusion

1. Identity verified:


Beneficiary: Yes No


Living-with Spouse: Yes No



No deficiency


Deficiency

___________________

___________________

___________________



2. Marital Status


No change/Verification not required


Documentary evidence


Divorce Decree Separation Agreement


Annulment Decree Death Certificate/SSA

records

Marriage Certificate


Collateral contact made:


Type/Date_________________________________


Place ____________________________________


Name/Title ________________________________


Findings ___________________________________


Documentary evidence unavailable


Explanation: ____________________________________

____________________________________

____________________________________










No change


Marital status

Change


No Living-with

Spouse


Living-with

Spouse


No deficiency


Deficiency

__________________

__________________

__________________






SSA Records Interview

3. In-kind Support and Maintenance (ISM)


ISM involved:

Yes No


Amount of ISM:

$____________

Lives alone Beneficiary and Living-with Spouse only

Lives with others Medical Facility Non-Medical Facility

Beneficiary/Living-with Spouse has Home Ownership/Rental

Liability

NAME

CONTRIBUTES TO HOUSEHOLD

AMOUNT


Yes No

$


Yes No

$


Yes No

$


Yes No

$


Yes No

$

Average Monthly Household Expenses

Type Amount Type Amount

Food $_______ Gas $_______

Rent $_______ Electricity $_______

Property Property

Tax $_______ Insurance $_______

Water $_______ Sewer $_______

Mortgage $_______ Heating/Fuel $_______

Garbage

Removal $_______

Total Average Monthly Household Expenses $_______

Outside Contributor:

Name: _____________________

Address: _____________________

_____________________

Phone: ( ) _________________

Monthly Amount: $___________


Non-Household Situation:

Beneficiary

Type: Medical Non-Medical

Address: ______________________

______________________

Date of Admission: _________

Date of Discharge: _________

Care Rate: $ _______ Facility/3rd Party Payment: $______

Living-with Spouse

Type: Medical Non-Medical

Address: ______________________

______________________

Date of Admission: _________

Date of Discharge: _________

Care Rate: $ _______ Facility/3rd Party Payment: $______


Verification Conclusion

3. In-Kind Support and Maintenance (ISM)

Home Ownership/Rental Liability


Average Monthly Household Expenses


Type Amount Type Amount

Food $______ Gas $______

Rent $______ Electricity $______

Property Property

Tax $______ Insurance $______

Water $______ Sewer $______

Mortgage $______ Heating/Fuel $______

Garbage

Removal $______

Total Monthly Household Expenses $______

Type of evidence submitted: ________________________

Contribution amount from other household member(s): $______

Food/shelter contributions from outside HH: $______

Contributor(s):

Name: ________________________________

Address: ________________________________

________________________________

Phone: ( ) __________________

Type/Date: _______________________________

Findings: _____________________________________

_____________________________________

_____________________________________


Non-Household Situation:

Beneficiary

Type: Medical Non-Medical

Address: ______________________

______________________

Date of Admission: _________

Date of Discharge: _________

Care Rate: $ _______ Facility/3rd Party Payment: $______

Living-with Spouse

Type: Medical Non-Medical

Address: ______________________

______________________

Date of Admission: _________

Date of Discharge: _________

Care Rate: $ _______ Facility/3rd Party Payment: $______

No ISM involved


Total Yearly ISM: $_____

No deficiency


Deficiency: ______

___________________

___________________

___________________

___________________



























SSA Records Interview

4. Family Size


Number of relatives living with the beneficiary and/or living-with spouse for whom they allege providing at least ½ financial support:


_____


Beneficiary


Living-with

Spouse


Total Alleged Family Size: ____




























Beneficiary/living-with spouse does not provide ½ support to

relatives in household.


Indicate below: the name, relationship, income and whether or not ½ support is alleged for each relative in the household of the beneficiary or living-with spouse.


NAME

RELATION-SHIP

INCOME

½ SUPPORT ALLEGED




Yes No




Yes No




Yes No




Yes No




Yes No




Yes No




Yes No




Yes No




Yes No
























Verification Conclusion

4. Family Size


Collateral Contact(s):


Name: _________________________

Address: _________________________

_________________________

_________________________

Phone: ( ) _____________

Findings: ______________________________________

______________________________________

Name: _________________________

Address: _________________________

_________________________

_________________________

Phone: ( ) _____________

Findings: ______________________________________

______________________________________


























Verified Family Size:

______


½ support met for:

__________________

__________________

__________________

__________________

__________________


½ support not met

for:

__________________

__________________

__________________

__________________

__________________


No Deficiency


Deficiency: __________________

__________________

__________________

__________________








SSA Records Interview

5. Liquid Resources


None


Bank Accounts: $______


Stocks, bonds, savings bonds, mutual funds, IRA or similar accounts: $______


Cash: $______


Other:_____________

__________________


$_______


Computer Match:

$_______




















Indicate the type(s) of liquid resources involved and the amount. Provide the information needed to contact collateral sources.


Applicant Living-with Spouse

None None

Cash $________ $_________

Checking Account $________ $_________

Savings Account $________ $_________

Cert. of Deposit $________ $_________

Mutual Funds $________ $_________

Credit Union Accts. $________ $_________

Other Bank Account

(Christmas Club, etc.) $________ $_________

Patient Accounts $________ $_________

Savings Bonds $________ $_________

Stocks/Bonds $________ $_________

Promissory Notes $________ $_________

401K Plans/Keogh

Accounts $________ $_________

Trusts $________ $_________

Other (Explain)

_________________ $________ $_________


Account type ___________ Account ID________________

Name of Source: _________________________________________

Address: ___________________________________________

___________________________________________

Owner(s): ___________________________________

Balance: $________


Account type _______ Account ID___________________

Name of Source: _________________________________________

Address: ___________________________________________

___________________________________________

Owner(s): __________________________________________

Balance: $________


Remarks: ________________________________________________

________________________________________________________

Verification Conclusion

5. Liquid Resources


Evidence viewed: Yes No


Account type _________ Account ID________________

Owner(s): _____________________________________

Balance: $_______


Account type _________ Account ID________________

Owner(s): _____________________________________

Balance: $_______


Account type _________ Account ID________________

Owner(s): _____________________________________

Balance: $_______


Collateral contact made?: Yes No


Name of Source:_________________________

Address: _______________________________

_______________________________

Account type _________ Account ID________________

Owner(s):______________________________________

Balance: $______________



Name of Source:_________________________

Address: _______________________________

_______________________________

Account type _________ Account ID________________

Owner(s):______________________________________

Balance: $______________



Name of Source:_________________________

Address: _______________________________

_______________________________

Account type _________ Account ID________________

Owner(s):______________________________________

Balance: $______________




None


Total Countable Liquid Resources:


Cash: $_____


Checking: $_____


Savings: $_____


Other: $_____


Total: $_____


Total countable liquid

resources did not

exceed resource limit

during the Evidentiary

Period.


Liquid resources caused

or contributed to

ineligibility or affected

the Subsidy Level.


No deficiency


Deficiency __________

______________________

______________________

______________________











SSA Records Interview


6. Life Insurance

Policy


Have policies with total face value of more than $1,500?


Beneficiary:


Yes No


Cash Surrender Value (CSV): $_______


Living-with Spouse:


Yes No


Cash Surrender Value (CSV): $_______



Life Insurance Policies owned by Beneficiary or Living-with Spouse? Yes, indicate below No


Type of Policy: Whole Life Term Life Other

Face Value: _____________ CSV: _________________

Dividend Accumulations: ________

Date of Issue: ________________________

Name of Insured Individual: _________________________

Owner of Policy: ___________________________________

Policy Number: ___________________________________

Name of Insurance Carrier:___________________________

Address of Carrier: ________________________________

________________________________

Phone: ( ) ___________________


Type of Policy: Whole Life Term Life Other

Face Value: _____________ CSV: _________________

Dividend Accumulations: ________

Date of Issue: ________________________

Name of Insured Individual: _________________________

Owner of Policy: ___________________________________

Policy Number: ___________________________________

Name of Insurance Carrier:___________________________

Address of Carrier: ________________________________

________________________________

Phone: ( ) ___________________


Type of Policy: Whole Life Term Life Other

Face Value: _____________ CSV: _________________

Dividend Accumulations: ________

Date of Issue: ________________________

Name of Insured Individual: _________________________

Owner of Policy: ___________________________________

Policy Number: ___________________________________

Name of Insurance Carrier:___________________________

Address of Carrier: ________________________________

________________________________

Phone: ( ) ___________________



Verification Conclusion

6. Life Insurance Policy

No policies


Collateral contact:


Name: _______________________________

Address: _______________________________

_______________________________

Phone: ( ) __________________


Total Face Value: ____________ CSV: ______________

Dividend Accumulations: ______________

Owner(s): ______________________________________

Name: _______________________________

Address: _______________________________

_______________________________

Phone: ( ) __________________


Total Face Value: $______ CSV: $_______

Dividend Accumulations: $_______

Owner(s): ______________________________________

Name: _______________________________

Address: _______________________________

_______________________________

Phone: ( ) __________________


Total Face Value: $______ CSV: $_______

Dividend Accumulations: $_______

Owner(s): ______________________________________

Name: _______________________________

Address: _______________________________

_______________________________

Phone: ( ) __________________


Total Face Value: $______ CSV: $_______

Dividend Accumulations: $_______


Owner(s): ______________________________________

Beneficiary


No policies


Face Value exceeds $1500

Yes No


CSV: $________

Dividend Accumulations:

$__________

Total countable value of Life Insurance: $_________


No Deficiency


Deficiency __________

___________________

___________________


Living-with Spouse


No policies


Face Value exceeds $1500

Yes No


CSV: $________

Dividend Accumulations:

$__________

Total countable value of Life Insurance: $_________


No Deficiency


Deficiency __________

___________________

___________________








SSA Records Interview

7. Non-home Real

Property


Ownership:


Yes No


CMV $ _________


































Allegation of Non-Home Real Property ownership by Beneficiary/Living-with Spouse:

Yes No


Sole Ownership

Beneficiary Living-with Spouse

Joint ownership

Joint owner’s Name: __________________________________

Address: __________________________________

__________________________________

Phone: ( ) ______________________

Property Address: ____________________________________

____________________________________

____________________________________


CMV: $_______ Mortgage balance: $________

Property Essential for Self-Support: $______

Lien Holder:

Name/Source: __________________________________

Address: __________________________________

__________________________________

Phone: ( ) ______________________

Encumbrances: ______________________________________

___________________________________________________


Sole ownership

Beneficiary Living-with Spouse

Joint ownership

Joint owner’s Name: __________________________________

Address: __________________________________

__________________________________

Phone: ( ) ______________________

Property Address: ____________________________________

____________________________________

____________________________________


CMV: $_______ Mortgage balance: $________

Property Essential for Self-Support: $______

Lien Holder:

Name/Source: __________________________________

Address: __________________________________

__________________________________

Phone: ( ) ______________________

Encumbrances: ______________________________________

___________________________________________________



Verification Conclusion

7. Non-Home Real Property


Allegations verified by:


Government records


Tax Assessment Statement


Other (i.e. deed, sales contract, etc.) __________________


Collateral contact made:


Name of Source: _______________________________

Address: ______________________________________

Owner(s): ______________________________________

Verified CMV: $__________ Equity Value: $__________


Name of Source: _______________________________

Address: ______________________________________

Owner(s): ______________________________________

Verified CMV: $__________ Equity Value: $___________


Encumbrances: _______________________________________

_____________________________________________________

_____________________________________________________

Property Essential for Self-Support: $______





No Non-Home Real

Property ownership for

Beneficiary or Living-

with Spouse


Beneficiary or Living-

with Spouse owns

excluded Non-Home

Real Property


Beneficiary or Living-

with Spouse owns

countable Non-Home

Real Property with a

total equity value of:

$ ________


Property Essential for

Self Support: $______


No deficiency


Deficiency: _________

______________________

______________________

______________________




















SSA Records Interview


8. Funeral/Burial

Expenses


Funds expected to be used for funeral or burial expenses?


Yes No



Funds expected to be used for funeral or burial expenses?


Yes No










































Verification Conclusion

8. Funeral/Burial Funds



Exclusion does not

apply


Exclusion applies


Beneficiary only


Living-with Spouse

only


Both


No deficiency


Deficiency:

_________________
_________________
_________________
_________________


Total Countable Resources Summary


Type of Resource Total Value


Liquid Resources $ ___________


Life Insurance Policies $ ___________


Non-Home Real Property $ ___________


Subtotal $___________


Minus Burial Fund Exclusion $___________

(If applicable)


Total $ ___________






No deficiency


Deficiency:

_________________
_________________
_________________
_________________
_________________


Resources caused ineligibility or affected the subsidy level:


Yes No




SSA Records Interview

9. Unearned Income


Beneficiary


None


Income type: ____________


Amount: $ ______


Income type: ____________


Amount: $ ______


Computer Match:

$______



Living-with Spouse


None


Income type: __________________


Amount: $ _________


Income type: __________________


Amount: $ _________


Computer Match:

$_______







Indicate the type(s) of unearned income involved and provide the amount and source of verification.

Beneficiary Living-with Spouse


Title II $________ $________

Title XVI $________ $________

Bank Deposits $________ $________

VA Pension $________ $________

VA

Compensation $________ $________

Gov’t Pension $________ $________

Private Pension $________ $________

Railroad Retire. $________ $________

Black Lung $________ $________

Educational

Assistance $________ $________

State Dib. Pymt $________ $________

Unemployment $________ $________

Worker’s Comp. $________ $________

Sick Pay $________ $________

Royalties $________ $________

Rental Income $________ $________

Gifts $________ $________

Alimony $________ $________

Patrimony $________ $________

Gambling

Proceeds $________ $________

Child Support $________ $________

Cash $________ $________

Other $________ $________

Source:

Name: ____________________________

Address: ____________________________

____________________________

Phone: ( )__________________

Claim #: ______________________


Name: ____________________________

Address: ____________________________

____________________________

Phone: ( )__________________

Claim #: ______________________


Verification Conclusion

9. Unearned Income


None

Title II (verified by the MBR)

Title XVI (verified by the SSR - Informational only)

Verified by award letter or other evidence in

Beneficiary’s/living-with Spouse’s possession.

Collateral contact made:

Source:___________________________________________

Addr: ___________________________________________

___________________________________________

Phone: ( ) _________________

Findings: _________________________________________

_________________________________________


Collateral contact made:


Source:___________________________________________

Addr: ___________________________________________

___________________________________________

Phone: ( ) _________________

Findings: _________________________________________

_________________________________________


Collateral contact made:


Source:___________________________________________

Addr: ___________________________________________

___________________________________________

Phone: ( ) _________________

Findings: _________________________________________

_________________________________________


Unearned Income exclusion established per HI 03020.ff

Type: ______________ Amount: $__________

Type: ______________ Amount: $__________

Type: ______________ Amount: $__________






Total Yearly Unearned Income


$ _____________


Total Yearly Excludable Unearned Income


$ _____________



Total Yearly Countable Unearned Income


$ _____________
































SSA Records Interview

10. Earned Income


Beneficiary


None


Wages: $ _______

SEI : $ _______


Amounts decreased:

Yes No


Stopped or plans to stop work?

Yes No

When? _________


Work expenses?

Yes No

Computer Match:

$_________


Living-with Spouse


None


Wages: $ _______

SEI : $ _______


Amounts decreased:

Yes No


Stopped or plans to stop work? Yes No

When? _________


Work expenses?

Yes No


Computer Match:

$_________





Date last worked: Beneficiary _______ Spouse_________

Date plans to stop work: Beneficiary _______ Spouse_________


Beneficiary Living-with Spouse


Wages $_________ $_________

NESE $_________ $_________

Sheltered

Workshop

Earnings $_________ $_________

Royalties $_________ $_________

Honoraria $_________ $_________

In-Kind Earned

Income $_________ $_________


Source Name: _____________________________________

Address : _____________________________________

_____________________________________

Phone : ( ) ____________________


Source Name: _____________________________________

Address : _____________________________________

_____________________________________

Phone : ( ) ____________________


Explanation of decrease in earnings: ___________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

Work Expenses


IRWE/BWE Yes No


Type(s): _______________________________________


Amount: $____________


Frequency: Weekly Monthly Yearly





Verification Conclusion

10. Earned Income and Earned Income Exclusions


None

Earned Income established:

See employer contact in file

See systems query (DEQY, SEQY)

See SSA-4201

See tax return

See copy of other business record

See summary of beneficiary’s/living-with Spouse’s

records (i.e. pay stubs)

Collateral contact made:

Source: ____________________________________

____________________________________

____________________________________

Date of Contact: ___________

Finding: ____________________________________

_____________________________________


Source: ____________________________________

____________________________________

____________________________________

Date of Contact: ___________

Finding: ____________________________________

____________________________________


Earned Income Exclusion established per HI 03020.ff:

Type: ______________ Amount: $__________

Type: ______________ Amount: $__________

Type: ______________ Amount: $__________


Work Expense(s) established:


IRWE BWE


Type: __________________________


Amount: $____________


Frequency: Weekly Monthly Yearly


Findings: ____________________________________________

____________________________________________________


Neither Beneficiary

nor Living-with

Spouse has Earned

Income


Beneficiary has

yearly Earned Income

of:

$ _____________


Living-with Spouse

has yearly Earned

Income of:

$ _____________


Total Yearly Earned Income:

$___________


Total Earned Income

Exclusion:

Type: ____________

Amount:$_________


Work Expense(s):


IRWE BWE:

$ _____________


Total Yearly Countable Earned Income:

$___________















Total Yearly Countable Income Summary


In Kind Support and Maintenance: $ ___________


Unearned Income: $ ___________


Earned Income: $ ___________




Total $ ___________

No deficiency


Deficiency:

_________________
_________________
_________________
_________________
_________________


Income caused ineligibility or affected the Subsidy Level:


Yes No



REMARKS/DEFICIENCY ANALYSIS


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REMARKS/DEFICIENCY ANALYSIS (continued)


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Reviewer’s Signature:


Date:




Attach all Reports of Contacts, Available Documentation, Other Related Worksheets and Continuation Pages.


22

Medicare Subsidy-Quality Review Case Analysis

SSA-9301 (04/2007)

File Typeapplication/msword
File TitleMEDICARE SUBSIDY - QUALITY REVIEW CASE ANALYSIS
Author364490
Last Modified BySME
File Modified2007-08-13
File Created2007-08-13

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