SSA-9301 Current Version

SSA-9301 Current Version.docx

Medicare Subsidy Quality Review

SSA-9301 Current Version

OMB: 0960-0707

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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:






SSA Records Interview

1. Identity

SSN

BN:

_______________


LWS:

_______________

Date of Birth


BN: __________________


LWS:

__________________



__________________

__________________

__________________



Remarks:















BN

SSN _______________________________________________

Name on Record_______________________________________________

Date of Birth _______________________________________________

Birthplace _______________________________________________

Parents _______________________________________________



LWS

SSN _______________________________________________

Name on Record_______________________________________________­­­­

Date of Birth _______________________________________________

Birthplace _______________________________________________

Parents _______________________________________________


Remarks:









Verification Conclusion

1.Identity


SSN agrees with systems queries

BN:

Yes No


LWS:

Yes No


Remarks:



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:


Household Composition

Check all applicable boxes:

BN

LWS

Deemed children. Number: ___

Other related individuals. Number: ___

Unrelated people in the HH. Number: ___

Total number people in household (HH) counting non relatives______


Indicate below: 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.)

NAME

RELATION-SHIP

INCOME

½ SUPPORT ALLEGED




Yes No Deemed




Yes No

Deemed




Yes No

Deemed




Yes No

Deemed




Yes No

Deemed




Yes No

Deemed




Yes No

Deemed




Yes No

Deemed




Yes No

Deemed


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:







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:










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:




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 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:



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:


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-Home

Real Property


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


________________
_________________
_________________
_________________




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.


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