Ssa-9301

FORM APPROVED
OMB No. 0960-0707

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

Subsidy Level: _______%

Sample Cycle: ____________
Interview date: ____________

Study ID: _________

2. Beneficiary’s (BN) SSN:____________
Living-with Spouse’s (LWS) SSN (If applicable):____________
Date Application Received__________
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:_________________________________________

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

No
Phone:(

Remarks:_____________________________________
______________

Medicare Subsidy – Quality Review Case Analysis
SSA-9301 (Rev 05-2023)

)______________

Remarks:_____________________________________________
_____________________________________________________

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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
1.

Conclusion

Identity

SSN agrees with systems
queries
BN:
Yes

No

LWS:
Yes

No

Proper BN/LWS interviewed
Yes
No

Remarks: :______________________________________________________
_______________________________________________________________

Remarks:______________
______________________

Medicare Subsidy – Quality Review Case Analysis
SSA-9301 (Rev 05-2023)

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SSA Records
2. Marital Status

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

Single, Divorced,
Widow(er),
Married Not LWS
Married LWS

Single, Divorced, Widow(er), Married Not LWS
Married LWS
Has there been any change in marital status since the application date?

Remarks:______________
______________________

Yes

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
(Verification
required)

Status
not

Conclusion

LWS
Yes

No

Deficiency
Remarks:_____________
_____________________

Yes

No

Remarks:___________________________________________________________
___________________________________________________________________

Medicare Subsidy – Quality Review Case Analysis
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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
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
Average Monthly HH Expenses
(Complete only when non deemed relative(s) live with BN/LWS)
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:__________________________________________________________
__________________________________________________________________

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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:__________
Difference
Yes
No
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.
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
1/2 support met for the following individuals.
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
1/2 support deemed for the following children.
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Remarks:__________________________________________________
_________________________________________________________

Medicare Subsidy – Quality Review Case Analysis
SSA-9301 (Rev 05-2023)

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

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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:_______________
_______________________

Medicare Subsidy – Quality Review Case Analysis
SSA-9301 (Rev 05-2023)

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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

No

Evidence provided by collateral contact
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:_____________________________________________________
_____________________________________________________________

Medicare Subsidy – Quality Review Case Analysis
SSA-9301 (Rev 05-2023)

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

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

Sole Ownership
BN
LWS
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 $_________
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:_____________________________________________________________
_____________________________________________________________________

Medicare Subsidy – Quality Review Case Analysis
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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
BN
LWS
owns countable NHRP-Home
Real Property with a total equity
value of: $ ________
BN
LWS
owns excludable NHRP-Home
Real Property
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:_______________________________________
_____________________________________________________
Property Essential for Self-Support: $______

Remarks:____________________________________________________
____________________________________________________________

Medicare Subsidy – Quality Review Case Analysis
SSA-9301 (Rev 05-2023)

No

No

Combined Deficiency
Yes

No

Remarks:_________________
_________________________

10
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

BN
Yes

No

LWS
Yes

No

No

Remarks:_________________________________________________________
_________________________________________________________________

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:_________________________________________________________
_________________________________________________________________

Medicare Subsidy – Quality Review Case Analysis
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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

Remarks:_________________________________________________________________________________
_________________________________________________________________________________________

Medicare Subsidy – Quality Review Case Analysis
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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________________________________________________________
_______________________________________________________________

Medicare Subsidy – Quality Review Case Analysis
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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:_________
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
$____________
$____________
$____________

Yearly Amount
$____________
$____________
$____________

Total Yearly Unearned Income $_________
Minus
Unearned Income Exclusion $ _________
Total Yearly Countable Unearned Income $ _________
Remarks:______________________________________________________
______________________________________________________________

Medicare Subsidy – Quality Review Case Analysis
SSA-9301 (Rev 05-2023)

UI:
BN

Yes

No

LWS:

Yes

No

Total Yearly Countable UI
$_____________
Difference
Yes

No

Stand Alone Deficiency
Yes

No

Combined Deficiency
Yes

No

Remarks:_________________
_________________________

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

: $ _______

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

Amounts decreased:
Yes

No

Stopped or plans to stop
work?
Yes

No

When? _________

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

: $ _______

Amounts decreased:
Yes

No

Stopped or plans to stop
work?
Yes

No

Source Name: _____________________________________
Address
: _____________________________________
_____________________________________
Phone: ( ) ____________________
Explanation of increase or decrease in earnings:__________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Cafeteria Plan

Yes

No

When? _________
Work expenses?
Yes

No

Computer Match:
$_________
Remarks:_____________
_____________________

Work Expenses
IRWE/BWE
Type(s): _______________________________________
Amount: $____________
Frequency:
Weekly
Monthly
Yearly
Remarks:________________________________________________________
________________________________________________________________

Medicare Subsidy – Quality Review Case Analysis
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15
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

Total Yearly Countable EI:
$___________

Collateral contact made:
Source: ____________________________________
__________________________________________
__________________________________________
Date of Contact:________
Total: $_______________
Source:____________________________________
__________________________________________
____________________________________
Date of Contact:________
Total: $______________________
Work Expense(s) established:
IRWE
BWE
Type:__________________________
Amount: $____________
Frequency:
Weekly
Monthly
Summary of Total Earned Income
Type of Income
Monthly Amount
_____________
$____________
_____________
$____________
_____________
$____________

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 $_________
Remarks: ____________________________________________
____________________________________________________

Medicare Subsidy – Quality Review Case Analysis
SSA-9301 (Rev 05-2023)

Difference
Yes

No

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

16
Total Yearly Countable Income Summary
Unearned Income:

$ ___________

Earned Income:

$ ___________

Total

$ ___________

Income caused ineligibility:
Yes

No

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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17

Reviewer’s Signature:

Date:

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

Medicare Subsidy – Quality Review Case Analysis
SSA-9301 (Rev 05-2023)