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 (LWS) SSN (If applicable): ____________
Date Application Received __________
3. Exclusion: Yes No
If yes, exclusion code: _______
If excluding, were Special Procedures considered? Yes No
________________________________________________________________________
Name of BN: _______________________
Address: ___________________________ ___________________________ ___________________________
Phone: ( ) ____________________
LWS: Yes No
LWS name: ____________________
LWS contacted:
Yes No
Remarks:
|
Other Contact:
Representative Payee (if applicable)
Name: ________________________
Address: _______________________
_______________________
Phone: ( ) ______________
Third Party
Name: ________________________
Address: ________________________
________________________
Phone: ( ) ______________
Remarks:
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SSA Records Interview
1. Identity
SSN BN: _______________
LWS: _______________
Date of Birth
BN: __________________
LWS: __________________
__________________ __________________ __________________
Remarks:
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BN SSN _______________________________________________ Name on Record_______________________________________________ Date of Birth _______________________________________________ Birthplace _______________________________________________ Parents _______________________________________________
LWS SSN _______________________________________________ Name on Record_______________________________________________ Date of Birth _______________________________________________ Birthplace _______________________________________________ Parents _______________________________________________
Remarks:
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Verification Conclusion
1.Identity
SSN agrees with systems queries
BN: Yes No
LWS: Yes No
Remarks:
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Proper BN/LWS interviewed Yes No
Remarks:
|
SSA Records Interview
2. Marital Status
Single, Divorced, Widow(er), Married Not LWS
Married LWS
Remarks:
|
What was your marital status at the time the application was filed?
Single, Divorced, Widow(er), Married Not LWS
Married LWS
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: __________________
Remarks: |
Verification Conclusion
2. Marital Status (Verification not required)
Remarks:
|
LWS
Yes No
Deficiency
Yes No
Remarks:
|
SSA Records Interview
3. Family Size (FS)
Number of relatives living with the BN/LWS for whom they allege providing at least ½ financial support:
_____
_____ Alleged FS (include BN/LWS)
Remarks:
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Household Composition Check all applicable boxes: BN LWS Deemed children. Number: ___ Other related individuals. Number: ___ Unrelated people in the HH. Number: ___
Total
number
In the chart below, show the name, relationship, income and whether or not ½ support is alleged for each relative in the HH of the BN or LWS. (If none, proceed to conclusion column for completion.)
Average Monthly HH Expenses
Type Amount Type Amount Food $_______ Gas $_______ Rent $_______ Electricity $_______ Property Property Tax $_______ Insurance $_______ Water $_______ Sewer $_______ Mortgage $_______ Heating/Fuel $_______ Garbage Removal $_______ Total Average Monthly HH Expenses $_______
Remarks: |
Verification Conclusion
3. FS Number of people in HH _____
Pro rata share (total monthly expenses divided by number of people in HH)________
1/2 support not met for the following individuals. _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________
1/2 support met for the following individuals. _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________
1/2 support deemed for the following children. _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________
Remarks:
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Total FS:__________
Difference Yes No
Stand Alone Deficiency Yes No
Combined Deficiency Yes No
___________________ ___________________ ___________________ ___________________
Remarks:
|
SSA Records Interview
4. Liquid Resources (LR)
No Liquid Resources
Bank Accounts: $______
Stocks, bonds, savings bonds, mutual funds, IRA or similar accounts: $______
Cash: $______
Other:_____________ __________________
$_______
Computer Match:
BN
Source: _______________ Amount:$______________ Source: _______________ Amount:$______________ Source: _______________ Amount:$______________ Source: _______________ Amount:$______________
LWS
Source: _______________ Amount:$______________ Source: _______________ Amount:$______________ Source: _______________ Amount:$______________ Source: _______________ Amount:$______________
Remarks:
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Indicate the type(s) of liquid resources involved and the amount. Provide the information needed to contact collateral sources.
BN LWS
No LR No LR 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
4. Liquid Resources
Evidence provided by BN: Yes No
Source document:________________________________ Account type __________Account ID__________________ Owner(s): _____________________________________ Balance: $_______
Source document:________________________________ Account type __________Account ID__________________ Owner(s): _____________________________________ Balance: $_______
Source document:________________________________ Account type __________Account ID__________________ Owner(s): _____________________________________ Balance: $_______
Evidence provided by collateral contact: 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: $______________
Remarks:
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No Liquid Resources
Total Countable LR:
Bank Accounts: $______
Stocks, etc: $______
Cash: $______
Other: $______
Total: $______
Total countable LR not over resource limit.
LR caused ineligibility.
LR affected co-pay/deductible only.
Difference Yes No
Stand Alone Deficiency Yes No
Combined Deficiency Yes No
Remarks:
|
|
|
SSA Records Interview
5. Non-home Real Property (NHRP)
Ownership:
Yes No
CMV $ _________
Accurint NHRP lead
Yes No
Lexis-Nexis Accurint NHRP lead for LWS
Yes No
Remarks:
|
Allegation of NHRP ownership by BN/LWS: Yes No
Sole Ownership BN LWS
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 BN LWS 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: ______________________________________ ___________________________________________________ Remarks:
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Verification Conclusion
5. Non-Home Real Property Accurint produced no NHRP leads for BN Lexus-Nexus produced no NHRP leads for LWS
Allegations verified by:
Government Records (e.g., Tax Assessment Statement)
Contact with applicable government records office (e.g., Assessor’s office) Date of contact __________________________________ Agency name ___________________________________ Name of contact _________________________________ Address ________________________________________ Method of Contact Letter Telephone Internet Other _______________________________________________
Other (e.g. deed, sales contract, etc.) __________________
Non-government collateral contact made Yes No
Name of Source: _______________________________ Address: ______________________________________ Method of Contact Letter Telephone Internet Other
NHRP found Yes No
Owner(s): ______________________________________ Verified CMV: $__________ Equity Value: $__________
_______________________________________________
Name of Source: _______________________________ Address: ______________________________________
Encumbrances: _______________________________________ _____________________________________________________ _____________________________________________________
Property Essential for Self-Support: $______
Remarks:
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Non-Home Real Property
BN: Yes No LWS: Yes No
BN or LWS owns countable NHRP-Home Real Property with a total equity value of: $ ________
BN or LWS owns excludable NHRP Property Essential for Self Support
Undue Hardship
Difference
Yes No
Stand Alone Deficiency
Yes No
Combined Deficiency
Yes No
Remarks:
|
SSA Records Interview
6. Funeral/Burial Expenses
Funds expected to be used for funeral or burial expenses?
Yes No
Remarks: |
Funds expected to be used for funeral or burial expenses?
Yes No
Remarks:
|
Verification Conclusion
6. Funeral/Burial Funds (Verification not required)
|
Exclusion does not apply
Exclusion applies
BN only
LWS only
Both
Difference
Yes No
Note: Difference may affect total resource amount.
Remarks: |
Total Countable Resources Summary
Type of Resource Total Value
Liquid Resources $ __________
Non-Home Real Property $__________
Subtotal $__________
Minus Burial Fund Exclusion $__________ (If applicable)
Total $ __________
Resources caused ineligibility: Yes No
Resources affected the co-pay/deductible only: Yes No
Remarks:
|
SSA Records Interview
7. Unearned Income (UI)
BN
No UI
Income type: ____________
Amount: $ ______
Income type: ____________
Amount: $ ______
Computer Match: Source:_______________ Amount: $____________
LWS
No UI
Income type: __________________
Amount: $ _________
Income type: __________________
Amount: $ _________
Computer Match: Source:_______________ Amount: $____________
Remarks:
|
Indicate the type(s) of Unearned Income involved and provide the amount and source of verification. BN LWS
No UI No UI Title II $________ $_________ BN receives no other unearned income LWS receives no other unearned income Title XVI $________ $________ Bank Deposits $________ $________ VA Pension $________ $________ VA Compensation $________ $________ Gov’t Pension $________ $________ Private Pension $________ $________ Railroad Retirement $________ $________ Black Lung $________ $________ Educational Assistance $________ $________ State Dib Payment $________ $________ 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 #: ______________________
Name: ____________________________ Address: ____________________________ ____________________________ Phone: ( )__________________ Claim #: ______________________
Name: ____________________________ Address: ____________________________ ____________________________ Phone: ( )__________________ Claim #: ______________________
Remarks |
Verification Conclusion
7. UI
Title II (verified by the MBR) Title XVI (verified by the SSR - Informational only) Verified by award letter or other evidence in BN/LWS possession.
Source:___________________________________________ Addr: ___________________________________________ ___________________________________________ Phone: ( ) _________________
Total Yearly Amount:__________
Source:___________________________________________ Addr: ___________________________________________ ___________________________________________ Phone: ( ) _________________
Total Yearly Amount:__________
Collateral contact made: Source:___________________________________________ Addr: ___________________________________________ ___________________________________________ Phone: ( ) _________________
Total Yearly Amount:__________
Source:___________________________________________ Addr: ___________________________________________ ___________________________________________ Phone: ( ) _________________
Total Yearly Amount:__________
Source:___________________________________________ Addr: ___________________________________________ ___________________________________________ Phone: ( ) _________________
Total Yearly Amount:__________
Summary of Total UI
Type of Income Yearly Amount _____________ $____________ _____________ $____________
Total Yearly Unearned Income $_________
Remarks:
|
Total Yearly Countable UI
$ _____________
Difference
Yes No
Stand Alone Deficiency
Yes No
Combined Deficiency
Yes No
Remarks:
|
SSA Records Interview
8. Earned Income (EI) BN No EI Wages: $ _______ SEI : $ _______ Amounts decreased: Yes No Stopped or plans to stop work? Yes No When? _________ Work expenses? Yes No Computer Match: $_________ LWS No EI Wages: $ _______ SEI : $ _______ Amounts decreased: Yes No Stopped or plans to stop work? Yes No When? _________ Work expenses? Yes No Computer Match: $_________ Remarks:
|
BN currently working: Yes No If No, date last employed:_____________________________
LWS currently working: Yes No If No, date last employed:_____________________________
BN LWS
No EI No EI Wages $_________ $_________ NESE $_________ $_________ Sheltered Workshop Earnings $_________ $_________ Royalties $_________ $_________ Honoraria $_________ $_________ In-Kind Earned Income $_________ $_________
Source Name: _____________________________________ Address : _____________________________________ _____________________________________ Phone : ( ) ____________________ Remarks:
Source Name: _____________________________________ Address : _____________________________________ _____________________________________ Phone : ( ) ____________________
Explanation of increase or decrease in earnings: __________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________
Work Expenses
IRWE/BWE Yes No
Type(s): _______________________________________
Amount: $____________
Frequency: Weekly Monthly Yearly
Remarks:
|
Verification Conclusion
8. EI and EI Exclusions
No EI EI established: Employer contact in file Systems query (DEQY, SEQY) Tax return Copy of other business record BN’s pay stubs Spouse’s pay stubs
Collateral contact made: Source: ____________________________________ ____________________________________ ____________________________________ Date of Contact: ___________ Total: $______________________
Source: ____________________________________ ____________________________________ ____________________________________ Date of Contact: ___________ Total: $______________________
Work Expense(s) established:
IRWE BWE
Type: __________________________
Amount: $____________
Frequency: Weekly Monthly Yearly
Remarks: ____________________________________________ ____________________________________________________
|
Neither BN nor LWS has EI
BN yearly countable EI : $ _____________
LWS yearly countable EI: $ _____________
Total Yearly Countable EI: $___________
Difference Yes No
Stand Alone Deficiency Yes No
Combined Deficiency Yes No
Remarks:
|
Total Yearly Countable Income Summary
Unearned Income: $ ___________
Earned Income: $ ___________
Total $ ___________ |
Income caused ineligibility or affected the Subsidy Level:
Yes No
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REMARKS/DEFICIENCY ANALYSIS
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REMARKS/DEFICIENCY ANALYSIS (continued)
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Reviewer’s Signature:
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Date:
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Attach all Reports of Contacts, Available Documentation, Other Related Worksheets and Continuation Pages.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | 233047 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |