SSA-9301 (revised)

FORM APPROVED
OMB No. 0960-0707

MEDICARE SUBSIDY - QUALITY REVIEW CASE ANALYSIS
1. QA Office Code: _________

__________
Subsidy Level:_______%

Sample Cycle: ____________

Study ID:

Interview date:____________

2. Beneficiary’s (BN) SSN:____________
Living-with Spouse’s (LWS) SSN (If applicable):____________
Date Application Received__________
Commented [PD1]: Reword for simplicity. Remove Yes box
and reword so only exclusion code entry is necessary.

3. Exclusion code if applicable: _______
________________________________________________________________________
Name of BN:_______________________

Other Contact (if applicable):

Address:______________________________________
________________

Representative Payee
Name:_________________________________________

Residence Address (if difference from Address):
___________________________
Phone: (
LWS:

)____________________
Yes

No

Address:_______________________________________
______________________________________________
Phone:(
)______________
Third Party
Name:_________________________________________

Commented [PD4]: Check boxes deleted for Representative
Payee and Third Party as redundant. Moved (if applicable) to Other
Contact so applies to both Representative Payee and Third Party
Commented [PD2]: Add Residence since Address may be PO
Box

Commented [PD3]: Add No box back for LWS and LWS
contacted

LWS name:____________________
Address:_______________________________________
LWS contacted:
______________________________________________
Yes

No
Phone:(

Remarks:_____________________________________
______________

)______________

Remarks:_____________________________________________
_____________________________________________________

SSA Records

Interview

1. Identity
SSN
BN:_______________
LWS:_______________

BN
SSN
Name on Record
Date of Birth
Birthplace
Parents

_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

LWS
SSN
Name on Record
Date of Birth
Birthplace
Parents

_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

Date of Birth
BN:_______________
LWS:_______________
Remarks______________
______

Remarks:______________________________________________________
______________________________________________________________

Verification

Conclusion

1.Identity
SSN agrees with systems
queries
BN:
Yes

No

LWS:
Yes

No

Proper BN/LWS interviewed
Yes
No

Commented [PD5]: Adds back Yes boxes for BN and LWS in
Verification and Conclusion.

Remarks: :______________________________________________________
_______________________________________________________________

Remarks:______________
______________________

2

SSA Records
2. Marital Status
Single, Divorced,
Widow(er),
Married Not LWS
Married LWS
Remarks:______________
______________________

Interview
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

Commented [PD6]: Add No box back.

No

If yes, indicate type of change below.
Divorce
Annulment
Marriage

Separation from Spouse
Death of your Spouse
Resumption of cohabitation after separation

Date of change: __________________
Remarks:___________________________________________________________
___________________________________________________________________

Verification
2.
Marital Status
(Verification not required)

LWS

Remarks:_____________
_____________________

Deficiency

Yes

Yes

Conclusion
Commented [PD7]: Add No box back for LWS and Deficiency

No

No

Remarks:___________________________________________________________
___________________________________________________________________

3

SSA Records
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:_____________
_____________________

Interview
Household Composition
If BN or BN and LWS live alone, check the appropriate box and proceed to Family
Size Verification column
BN lives alone
BN and LWS live alone

Commented [PD8]: Wording added for clarification.

If BN or BN and LWS live with others complete the following:
Check all applicable boxes:
BN
LWS
Deemed children. Number:___
Other related individuals. Number:___
Unrelated people in the HH. Number:___
Total number in household (HH) from boxes checked above______
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.)
NAME
RELATIONINCOME
½ SUPPORT
SHIP
ALLEGED
Yes
No
Deemed
Yes
No
Deemed
Yes
No
Deemed
Yes
No
Deemed
Yes
No
Deemed
Yes
No
Deemed

Commented [PD9]: Adds back all No boxes

Average Monthly HH Expenses
(Complete only when non deemed relative(s) live with BN/LWS)

Commented [PD10]: Clarification

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:__________________________________________________________
__________________________________________________________________

4

Verification
3. FS
If BN or BN and LWS live alone, check the appropriate box and complete FS
Conclusion column.
BN lives alone
BN and LWS live alone
If BN or BN and LWS live with others complete the following:

Conclusion
Total FS:__________
Commented [PD11]: Clarifies next action

Difference
Yes
No

Commented [PD12]: Adds back No boxes for Difference, Stand
Alone and Combined Deficiency

Stand Alone Deficiency
Yes
No

Number of people in HH _____ (including the BN and LWS)
Pro rata share (total monthly expenses divided by number of people in
HH)________
1/2 support not met for the following individuals.
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

Combined Deficiency
Yes
No
___________________
___________________
___________________
___________________
Remarks:_________________
_________________________

1/2 support met for the following individuals.
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
1/2 support deemed for the following children.
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Remarks:__________________________________________________
_________________________________________________________

5

SSA Records
4. Liquid Resources (LR)

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

No Liquid Resources
BN
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:$______________

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) _________________

LWS
No LR
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________
$_________

Account type___________ Account ID___________________
Name of Source:_____________________________________
Address: ___________________________________________
___________________________________________
Owner(s):__________________________________________
Balance: $________

Source: _______________
Amount:$______________

Account type _______Account ID_____________________________
Name of Source:___________________________________________
Address:_________________________________________________
_________________________________________________
Owner(s):________________________________________________
Balance:$________

Source: _______________
Amount:$______________

Remarks:________________________________________________
________________________________________________________

LWS

Source: _______________
Amount:$______________
Source: _______________
Amount:$______________
Remarks:_______________
_______________________

6

Verification
4. Liquid Resources
Evidence provided by BN:
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: $_______

Conclusion
No Liquid Resources
Bank Accounts: $______
(Checking, Savings, CD)
Stocks, bonds, savings
bonds, mutual funds,
IRA or other similar
Investments:
$______
Cash:

$______

Other

$______

Total:

$______

Difference
Yes

Commented [PD13]: Deleted LR caused ineligibility. Is not
needed.

No

Commented [PD14]: Add No box back for Difference, Stand
Alone and Combined Deficiency

Evidence provided by collateral contact
Name of Source:_________________________________
Address: _______________________________________
_______________________________________________
Account type _________ Account ID________________
Owner(s):______________________________________
Balance: $______________

Stand Alone Deficiency
Yes
No
Combined Deficiency
Yes
No
Remarks: _________________
_________________________

Name of Source:_________________________________
Address: _______________________________________
_______________________________________________
Account type _________ Account ID________________
Owner(s):______________________________________
Balance:$______________
Name of Source:_________________________________
Address: _______________________________________
_______________________________________________
Account type _________ Account ID________________
Owner(s):______________________________________
Balance: $______________
Remarks:_____________________________________________________
_____________________________________________________________

7

SSA Records
5. Non-home Real
Property (NHRP)

Sole Ownership
BN
LWS

Ownership:
Yes

No

CMV $ _________
Accurint NHRP lead for
BN
Yes

No

Accurint NHRP lead for
LWS
Yes

Interview
Allegation of NHRP ownership by BN/LWS:
Yes
No

No

Remarks:______________
______________________

Joint ownership
Joint owner’s Name:_________________________________
Address:________________________________________________________________
Phone:(
)______________________
Property Address:____________________________________
____________________________________
CMV:$_______
Mortgage balance: $________
Equity Value $_________

Commented [PD15]: Add back No box in Ownership, Accurint
NHRP leads for BN and LWS.

Commented [PD16]: Added “for BN” to match wording for
LWS
Commented [PD17]: Added Equity Value

Property Essential for Self-Support: $______
Lien Holder:__________________________________
Name/Source:__________________________________
Address:
__________________________________
__________________________________
Phone:
( )______________________
Encumbrances:______________________________________
___________________________________________________
Ownership
BN
LWS
Joint ownership
Joint owner’s Name:__________________________________
Address:__________________________________
__________________________________
Phone: ( )______________________
Property Address:____________________________________
____________________________________
____________________________________
CMV: $_______
Mortgage balance: $________
Equity Value $______
Property Essential for Self-Support: $______
Lien Holder:
Name/Source:__________________________________
Address:
__________________________________
__________________________________
Phone: ( )________________________
Encumbrances:______________________________________
___________________________________________________
Remarks:_____________________________________________________________
_____________________________________________________________________

8

Commented [PD18]: Removed Sole for clarification

Verification
5. Non-Home Real Property
Accurint produced NHRP leads for BN or LWS that affects the subsidy
level
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/Internet address____________________________________
Method of Contact Letter
Telephone
Internet
Other
_______________________________________________

Conclusion
Non-Home Real Property:
No NHRP
Commented [PD19]: Reworded for clarify.

BN
LWS
owns countable NHRP-Home
Real Property with a total equity
value of: $ ________
BN
LWS
owns excludable NHRP-Home
Real Property
Commented [PD20]: Adds internet address

Property Essential for
Self Support
Undue Hardship

Other (e.g. deed, sales contract, etc.) __________________
Difference
Non-government collateral contact made
Name of Source:_______________________________
Address/Internet Address:______________________________________
Method of Contact Letter
Telephone
Internet
Other
________________________________________________

Yes

Stand Alone Deficiency
Yes

NHRP found
Owner(s):______________________________________
Verified CMV: $__________ Equity Value: $__________
Name of Source:_______________________________
Address:___________________________________________
__________________________________________________
Encumbrances:_______________________________________
_____________________________________________________

Commented [PD21]: Adds back No box for Difference, Stand
Alone and Combined Deficiency

No

No

Combined Deficiency
Yes

No

Remarks:_________________
_________________________

Property Essential for Self-Support: $______

Remarks:____________________________________________________
____________________________________________________________

9

SSA Records
6. Funeral/Burial
Expenses
Funds expected to be used
for funeral or burial
expenses?

Interview
Funds expected to be used for funeral or burial expenses?
Beneficiary
Yes
No
LWS
Yes

Commented [PD22]: Added no boxes back in for SSA Records,
Interview, and Conclusion
Commented [PD23]: SSA Records and Interview, separated
Beneficiary and LWS answers since could be separate answers.

No

BN
Yes
LWS
Yes

No
Remarks:_________________________________________________________
_________________________________________________________________
No

Remarks:______________
______________________

Verification
6. Funeral/Burial Funds
(Verification not required)

Conclusion
Exclusion does not apply
Exclusion applies
BN only
LWS only
Both
Difference
Yes

No

Note: Difference may affect total resource amount.
Remarks:_________________________________________________________
_________________________________________________________________

10

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

Commented [PD24]: Adds back No box

No

Remarks:_________________________________________________________________________________
_________________________________________________________________________________________

11

SSA Records

Interview

7. Unearned Income (UI)
Indicate the type(s) of Unearned Income involved and provide the amount and
source of verification.
BN
LWS

BN
No UI

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:_____________
_____________________

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 #:
______________________
Remarks________________________________________________________
_______________________________________________________________

12

Verification

Conclusion

7. UI
Title II (verified by the MBR)
Title XVI (verified by the SSR - Informational only – not used for subsidy
determination)
Verified by award letter or other evidence in BN/LWS possession
Source:____________________________________________
Address:___________________________________________
___________________________________________
Phone:( )_________________
Total Yearly Amount:________
Source:____________________________________________
Address:___________________________________________
___________________________________________
Phone:( )_________________
Total Yearly Amount:________
Collateral contact made:
Source:____________________________________________
Address:___________________________________________
___________________________________________
Phone:( ) _________________
Total Yearly Amount:_________

UI:
BN

Yes

No

LWS:

Yes

No

Commented [PD27]: Adds back No box for BN and LWS,
Difference, Stand Alone Deficiency, and Combined Deficiency

Commented [PD28]: Deleted Social Security, Railroad
Retirement, Veterans, Other pensions and Other Income. It is
unnecessary to list separately.

Total Yearly Countable UI
$_____________
Difference
Yes

No

Stand Alone Deficiency
Yes

No

Combined Deficiency
Yes

No

Remarks:_________________
_________________________

Source:____________________________________________
Address:___________________________________________
___________________________________________
Phone:( )_________________
Total Yearly Amount:________
Source:____________________________________________
Address:___________________________________________
___________________________________________
Phone:( )_________________
Total Yearly Amount:________
Summary of Total UI (Drop all cents for monthly amounts of UI except Social
Security before converting to a yearly amount)
Type of Income
_____________
_____________
_____________

Monthly Amount
$____________
$____________
$____________

Commented [PD25]: Added Monthly for ease when calculating
yearly amount

Yearly Amount
$____________
$____________
$____________

Total Yearly Unearned Income $_________
Minus
Unearned Income Exclusion $ _________
Total Yearly Countable Unearned Income $ _________

Commented [PD26]: Moved calculations here rather than
showing in Conclusion column.

Remarks:______________________________________________________
______________________________________________________________

13

SSA Records
8. Earned Income (EI)
BN
No EI
Wages: $ _______
SEI

: $ _______

Interview

LWS currently working:
Yes
No
If No, date last employed:_____________________________

Amounts decreased:
Yes

No

Stopped or plans to stop
work?
Yes

No

When? _________

Commented [PD29]: Adds back No box BN and LWS

BN currently working:
Yes
No
If No, date last employed:_____________________________

Wages
NESE
Sheltered Workshop Earnings
Royalties
Honoraria
In-Kind Earned Income

BN

LWS

No EI
$_________
$_________
$_________
$_________
$_________
$_________

No EI
$_________
$_________
$_________
$_________
$_________
$_________

Work expenses?
Yes

No

Computer Match:
$_________

Source Name: _____________________________________
Address
: _____________________________________
_____________________________________
Phone: ( ) ____________________
Remarks:

LWS
No EI
Wages: $ _______
SEI

: $ _______

Source Name: _____________________________________
Address
: _____________________________________
_____________________________________
Phone: ( ) ____________________

Amounts decreased:
Yes

No

Stopped or plans to stop
work?
Yes

Explanation of increase or decrease in earnings:__________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

No

When? _________

Cafeteria Plan

Work expenses?

Work Expenses

Yes

No

Computer Match:
$_________

Yes

Commented [PD30]: Adds back No box

No

IRWE/BWE
Type(s): _______________________________________
Amount: $____________
Frequency:
Weekly
Monthly
Yearly

Remarks:_____________
_____________________

Remarks:________________________________________________________
________________________________________________________________

14

Verification

Conclusion

8. EI and EI Exclusions

BN

Yes

No

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

LWS:

Yes

No

Deleted:

Source:____________________________________
__________________________________________
____________________________________
Date of Contact:________
Total: $______________________

Summary of Total Earned Income
Type of Income
Monthly Amount
_____________
$____________
_____________
$____________
_____________
$____________

Difference
Yes

Neither BN nor LWS has EI¶

Commented [PD33]: Deleted Wages and SEI boxes. No need
for these boxes.

Total Yearly Countable EI:
$___________

Collateral contact made:
Source: ____________________________________
__________________________________________
__________________________________________
Date of Contact:________
Total: $_______________

Work Expense(s) established:
IRWE
BWE
Type:__________________________
Amount: $____________
Frequency:
Weekly
Monthly

Commented [PD32]: Deleted Neither BN nor LWS has EI.
Replaced with language for UI Conclusion for consistency.

Commented [PD34]: Adds back No box for Difference, Stand
Alone and Combined Deficiency

No

Stand Alone Deficiency
Yes
No
Combined Deficiency
Yes
No
Remarks:_______________
_______________________

Yearly

Yearly Amount
$____________
$____________
$____________

Total Yearly Earned Income $_________
Minus
Earned Income Exclusion (1) $_________
Earned Income Exclusion (2) $_________
Earned Income Exclusion (3) $_________
Total $_________
Divide Total in half. Enter in Total Yearly Countable Unearned Income
Total Yearly Countable Earned Income $_________

Commented [PD31]: Added section to mimic UI for
consistency. Removed calculation from Conclusion as it makes
more sent to have in Verification column.

Remarks: ____________________________________________
____________________________________________________

15

Total Yearly Countable Income Summary
Unearned Income:

$ ___________

Commented [PD36]: Deleted below. No longer required for
this review.

Earned Income:

$ ___________

Deleted: Income caused ineligibility or affected the Subsidy
Level: ¶
¶
Yes No¶

Total

$ ___________

REMARKS/DEFICIENCY ANALYSIS
The beneficiary allegation or verified amount for resources causes ineligibility. Further development ceased and
deficiency coded.
The beneficiary allegation or verified amount for income and family size causes ineligibility. Further
development ceased and deficiency coded.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

16

Commented [PD37]: Added check boxes and statements to save
time for reviewers.

Reviewer’s Signature:

Date:

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

17