FORM APPROVED
OMB No. 0960-0707
MEDICARE SUBSIDY - QUALITY REVIEW CASE ANALYSIS
1. QA Office Code: _________ Sample Cycle: ____________ Study ID: __________
Subsidy Level: _______% Interview date: ____________
2. Beneficiary’s (BN) SSN: ____________
Living-with Spouse’s SSN (If applicable): ____________
Type of Application: Beneficiary Only Beneficiary/Living-with Spouse
Date Application Filed: __________ Protective Filing Date/MOE: ___________
If death precluded interview, provide date of death & exclude: ____________
Other Exclusion (see remarks) Interview Incomplete (see remarks)
________________________________________________________________________
Name of BN: _______________________
Address: ___________________________ ___________________________ ___________________________
Phone: ( ) ____________________
Living-with Spouse: Yes No
Name of Spouse: ____________________
Living-with Spouse contacted:
Yes No
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Other Contact:
Representative Payee (if applicable)
Name: ________________________
Address: _______________________
_______________________
Phone: ( ) ______________
Third Party
Name: ________________________
Address: ________________________
________________________
Phone: ( ) ______________
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SSA Records Interview
1. Identity
SSN: Beneficiary: _______________
Living-with Spouse: _______________
Date of Birth
Beneficiary: __________________
Living-with Spouse: __________________ __________________ 2. Marital Status
Single, Divorced, Widow(er), Married Not Living-with Spouse
Married Living- with Spouse
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SSN agrees with systems queries
Beneficiary Living-with Spouse
_________________ Name on Record ____________________ _________________ Date of Birth ____________________ _________________ Birthplace ____________________ _________________ Parents ____________________ _________________ ____________________
_________________________________________________________ What was your marital status at the time the application was filed?
Single, Divorced, Widow(er), Married Not Living-with Spouse
Married Living-with Spouse
Has there been any change in marital status since the application date?
Yes No
If yes, indicate type of change below.
Divorce Separation from Spouse Annulment Death of your Spouse Marriage Resumption of cohabitation after separation
Date of change: __________________
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Verification Conclusion
1. Identity verified:
Beneficiary: Yes No
Living-with Spouse: Yes No
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No deficiency
Deficiency ___________________ ___________________ ___________________
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2. Marital Status
No change/Verification not required
Documentary evidence
Divorce Decree Separation Agreement
Annulment Decree Death Certificate/SSA records Marriage Certificate
Collateral contact made:
Type/Date_________________________________
Place ____________________________________
Name/Title ________________________________
Findings ___________________________________
Documentary evidence unavailable
Explanation: ____________________________________ ____________________________________ ____________________________________
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No change
Marital status Change
No Living-with Spouse
Living-with Spouse
No deficiency
Deficiency __________________ __________________ __________________
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SSA Records Interview
3. In-kind Support and Maintenance (ISM)
ISM involved:
Yes No
Amount of ISM: $____________ |
Lives alone Beneficiary and Living-with Spouse only Lives with others Medical Facility Non-Medical Facility Beneficiary/Living-with Spouse has Home Ownership/Rental Liability
Average Monthly Household Expenses
Type Amount Type Amount Food $_______ Gas $_______ Rent $_______ Electricity $_______ Property Property Tax $_______ Insurance $_______ Water $_______ Sewer $_______ Mortgage $_______ Heating/Fuel $_______ Garbage Removal $_______ Total Average Monthly Household Expenses $_______ Outside Contributor: Name: _____________________ Address: _____________________ _____________________ Phone: ( ) _________________ Monthly Amount: $___________
Non-Household Situation: Beneficiary Type: Medical Non-Medical Address: ______________________ ______________________ Date of Admission: _________ Date of Discharge: _________ Care Rate: $ _______ Facility/3rd Party Payment: $______ Living-with Spouse Type: Medical Non-Medical Address: ______________________ ______________________ Date of Admission: _________ Date of Discharge: _________ Care Rate: $ _______ Facility/3rd Party Payment: $______ |
Verification Conclusion
3. In-Kind Support and Maintenance (ISM)
Home Ownership/Rental Liability
Average Monthly Household Expenses
Type Amount Type Amount Food $______ Gas $______ Rent $______ Electricity $______ Property Property Tax $______ Insurance $______ Water $______ Sewer $______ Mortgage $______ Heating/Fuel $______ Garbage Removal $______ Total Monthly Household Expenses $______ Type of evidence submitted: ________________________ Contribution amount from other household member(s): $______ Food/shelter contributions from outside HH: $______ Contributor(s): Name: ________________________________ Address: ________________________________ ________________________________ Phone: ( ) __________________ Type/Date: _______________________________ Findings: _____________________________________ _____________________________________ _____________________________________
Non-Household Situation: Beneficiary Type: Medical Non-Medical Address: ______________________ ______________________ Date of Admission: _________ Date of Discharge: _________ Care Rate: $ _______ Facility/3rd Party Payment: $______
Living-with Spouse Type: Medical Non-Medical Address: ______________________ ______________________ Date of Admission: _________ Date of Discharge: _________ Care Rate: $ _______ Facility/3rd Party Payment: $______ |
No ISM involved
Total Yearly ISM: $_____
No deficiency
Deficiency: ______ ___________________ ___________________ ___________________ ___________________
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SSA Records Interview
4. Family Size
Number of relatives living with the beneficiary and/or living-with spouse for whom they allege providing at least ½ financial support:
_____
Beneficiary
Living-with Spouse
Total Alleged Family Size: ____
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Beneficiary/living-with spouse does not provide ½ support to relatives in household.
Indicate below: the name, relationship, income and whether or not ½ support is alleged for each relative in the household of the beneficiary or living-with spouse.
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Verification Conclusion
4. Family Size
Collateral Contact(s):
Name: _________________________ Address: _________________________ _________________________ _________________________ Phone: ( ) _____________ Findings: ______________________________________ ______________________________________
Name: _________________________ Address: _________________________ _________________________ _________________________ Phone: ( ) _____________ Findings: ______________________________________ ______________________________________
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Verified Family Size: ______
½ support met for: __________________ __________________ __________________ __________________ __________________
½ support not met for: __________________ __________________ __________________ __________________ __________________
No Deficiency
Deficiency: __________________ __________________ __________________ __________________
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SSA Records Interview
5. Liquid Resources
None
Bank Accounts: $______
Stocks, bonds, savings bonds, mutual funds, IRA or similar accounts: $______
Cash: $______
Other:_____________ __________________
$_______
Computer Match: $_______
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Indicate the type(s) of liquid resources involved and the amount. Provide the information needed to contact collateral sources.
Applicant Living-with Spouse None None
Cash $________ $_________ Checking Account $________ $_________ Savings Account $________ $_________ Cert. of Deposit $________ $_________ Mutual Funds $________ $_________ Credit Union Accts. $________ $_________ Other Bank Account (Christmas Club, etc.) $________ $_________ Patient Accounts $________ $_________ Savings Bonds $________ $_________ Stocks/Bonds $________ $_________ Promissory Notes $________ $_________ 401K Plans/Keogh Accounts $________ $_________ Trusts $________ $_________ Other (Explain) _________________ $________ $_________
Account type ___________ Account ID________________ Name of Source: _________________________________________ Address: ___________________________________________ ___________________________________________ Owner(s): ___________________________________ Balance: $________
Account type _______ Account ID___________________ Name of Source: _________________________________________ Address: ___________________________________________ ___________________________________________ Owner(s): __________________________________________ Balance: $________
Remarks: ________________________________________________ ________________________________________________________ |
Verification Conclusion
5. Liquid Resources
Evidence viewed: Yes No
Account type _________ Account ID________________ Owner(s): _____________________________________ Balance: $_______
Account type _________ Account ID________________ Owner(s): _____________________________________ Balance: $_______
Account type _________ Account ID________________ Owner(s): _____________________________________ Balance: $_______
Collateral contact made?: Yes No
Name of Source:_________________________ Address: _______________________________ _______________________________ Account type _________ Account ID________________ Owner(s):______________________________________ Balance: $______________
Name of Source:_________________________ Address: _______________________________ _______________________________ Account type _________ Account ID________________ Owner(s):______________________________________ Balance: $______________
Name of Source:_________________________ Address: _______________________________ _______________________________ Account type _________ Account ID________________ Owner(s):______________________________________ Balance: $______________
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None
Total Countable Liquid Resources:
Cash: $_____
Checking: $_____
Savings: $_____
Other: $_____
Total: $_____
Total countable liquid resources did not exceed resource limit during the Evidentiary Period.
Liquid resources caused or contributed to ineligibility or affected the Subsidy Level.
No deficiency
Deficiency __________ ______________________ ______________________ ______________________
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SSA Records Interview
6. Life Insurance Policy
Have policies with total face value of more than $1,500?
Beneficiary:
Yes No
Cash Surrender Value (CSV): $_______
Living-with Spouse:
Yes No
Cash Surrender Value (CSV): $_______
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Life Insurance Policies owned by Beneficiary or Living-with Spouse? Yes, indicate below No
Type of Policy: Whole Life Term Life Other Face Value: _____________ CSV: _________________ Dividend Accumulations: ________ Date of Issue: ________________________ Name of Insured Individual: _________________________ Owner of Policy: ___________________________________ Policy Number: ___________________________________ Name of Insurance Carrier:___________________________ Address of Carrier: ________________________________ ________________________________ Phone: ( ) ___________________
Type of Policy: Whole Life Term Life Other Face Value: _____________ CSV: _________________ Dividend Accumulations: ________ Date of Issue: ________________________ Name of Insured Individual: _________________________ Owner of Policy: ___________________________________ Policy Number: ___________________________________ Name of Insurance Carrier:___________________________ Address of Carrier: ________________________________ ________________________________ Phone: ( ) ___________________
Type of Policy: Whole Life Term Life Other Face Value: _____________ CSV: _________________ Dividend Accumulations: ________ Date of Issue: ________________________ Name of Insured Individual: _________________________ Owner of Policy: ___________________________________ Policy Number: ___________________________________ Name of Insurance Carrier:___________________________ Address of Carrier: ________________________________ ________________________________ Phone: ( ) ___________________
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Verification Conclusion
6. Life Insurance Policy
No policies
Collateral contact:
Name: _______________________________ Address: _______________________________ _______________________________ Phone: ( ) __________________
Total Face Value: ____________ CSV: ______________ Dividend Accumulations: ______________ Owner(s): ______________________________________
Name: _______________________________ Address: _______________________________ _______________________________ Phone: ( ) __________________
Total Face Value: $______ CSV: $_______ Dividend Accumulations: $_______ Owner(s): ______________________________________
Name: _______________________________ Address: _______________________________ _______________________________ Phone: ( ) __________________
Total Face Value: $______ CSV: $_______ Dividend Accumulations: $_______
Owner(s): ______________________________________
Name: _______________________________ Address: _______________________________ _______________________________ Phone: ( ) __________________
Total Face Value: $______ CSV: $_______ Dividend Accumulations: $_______
Owner(s): ______________________________________
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Beneficiary
No policies
Face Value exceeds $1500 Yes No
CSV: $________ Dividend Accumulations: $__________ Total countable value of Life Insurance: $_________
No Deficiency
Deficiency __________ ___________________ ___________________
Living-with Spouse
No policies
Face Value exceeds $1500 Yes No
CSV: $________ Dividend Accumulations: $__________ Total countable value of Life Insurance: $_________
No Deficiency
Deficiency __________ ___________________ ___________________
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SSA Records Interview
7. Non-home Real Property
Ownership:
Yes No
CMV $ _________
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Allegation of Non-Home Real Property ownership by Beneficiary/Living-with Spouse: Yes No
Sole Ownership Beneficiary Living-with Spouse Joint ownership Joint owner’s Name: __________________________________ Address: __________________________________ __________________________________ Phone: ( ) ______________________ Property Address: ____________________________________ ____________________________________ ____________________________________
CMV: $_______ Mortgage balance: $________ Property Essential for Self-Support: $______ Lien Holder: Name/Source: __________________________________ Address: __________________________________ __________________________________ Phone: ( ) ______________________ Encumbrances: ______________________________________ ___________________________________________________
Sole ownership Beneficiary Living-with Spouse Joint ownership Joint owner’s Name: __________________________________ Address: __________________________________ __________________________________ Phone: ( ) ______________________ Property Address: ____________________________________ ____________________________________ ____________________________________
CMV: $_______ Mortgage balance: $________ Property Essential for Self-Support: $______ Lien Holder: Name/Source: __________________________________ Address: __________________________________ __________________________________ Phone: ( ) ______________________ Encumbrances: ______________________________________ ___________________________________________________
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Verification Conclusion
7. Non-Home Real Property
Allegations verified by:
Government records
Tax Assessment Statement
Other (i.e. deed, sales contract, etc.) __________________
Collateral contact made:
Name of Source: _______________________________ Address: ______________________________________ Owner(s): ______________________________________ Verified CMV: $__________ Equity Value: $__________
Name of Source: _______________________________ Address: ______________________________________ Owner(s): ______________________________________ Verified CMV: $__________ Equity Value: $___________
Encumbrances: _______________________________________ _____________________________________________________ _____________________________________________________
Property Essential for Self-Support: $______
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No Non-Home Real Property ownership for Beneficiary or Living- with Spouse
Beneficiary or Living- with Spouse owns excluded Non-Home Real Property
Beneficiary or Living- with Spouse owns countable Non-Home Real Property with a total equity value of:
$ ________
Property Essential for Self Support: $______
No deficiency
Deficiency: _________ ______________________ ______________________ ______________________
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SSA Records Interview
8. Funeral/Burial Expenses
Funds expected to be used for funeral or burial expenses?
Yes No
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Funds expected to be used for funeral or burial expenses?
Yes No
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Verification Conclusion
8. Funeral/Burial Funds
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Exclusion does not apply
Exclusion applies
Beneficiary only
Living-with Spouse only
Both
No deficiency
Deficiency: _________________ |
Total Countable Resources Summary
Type of Resource Total Value
Liquid Resources $ ___________
Life Insurance Policies $ ___________
Non-Home Real Property $ ___________
Subtotal $___________
Minus Burial Fund Exclusion $___________ (If applicable)
Total $ ___________
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No deficiency
Deficiency: _________________
Resources caused ineligibility or affected the subsidy level:
Yes No
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SSA Records Interview
9. Unearned Income
Beneficiary
None
Income type: ____________
Amount: $ ______
Income type: ____________
Amount: $ ______
Computer Match: $______
Living-with Spouse
None
Income type: __________________
Amount: $ _________
Income type: __________________
Amount: $ _________
Computer Match: $_______
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Indicate the type(s) of unearned income involved and provide the amount and source of verification.
Beneficiary Living-with Spouse
Title II $________ $________ Title XVI $________ $________ Bank Deposits $________ $________ VA Pension $________ $________ VA Compensation $________ $________ Gov’t Pension $________ $________ Private Pension $________ $________ Railroad Retire. $________ $________ Black Lung $________ $________ Educational Assistance $________ $________ State Dib. Pymt $________ $________ Unemployment $________ $________ Worker’s Comp. $________ $________ Sick Pay $________ $________ Royalties $________ $________ Rental Income $________ $________ Gifts $________ $________ Alimony $________ $________ Patrimony $________ $________ Gambling Proceeds $________ $________ Child Support $________ $________ Cash $________ $________ Other $________ $________
Source: Name: ____________________________ Address: ____________________________ ____________________________ Phone: ( )__________________ Claim #: ______________________
Name: ____________________________ Address: ____________________________ ____________________________ Phone: ( )__________________ Claim #: ______________________
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Verification Conclusion
9. Unearned Income
None Title II (verified by the MBR) Title XVI (verified by the SSR - Informational only) Verified by award letter or other evidence in Beneficiary’s/living-with Spouse’s possession. Collateral contact made: Source:___________________________________________ Addr: ___________________________________________ ___________________________________________ Phone: ( ) _________________ Findings: _________________________________________ _________________________________________
Collateral contact made:
Source:___________________________________________ Addr: ___________________________________________ ___________________________________________ Phone: ( ) _________________ Findings: _________________________________________ _________________________________________
Collateral contact made:
Source:___________________________________________ Addr: ___________________________________________ ___________________________________________ Phone: ( ) _________________ Findings: _________________________________________ _________________________________________
Unearned Income exclusion established per HI 03020.ff
Type: ______________ Amount: $__________ Type: ______________ Amount: $__________ Type: ______________ Amount: $__________
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Total Yearly Unearned Income
$ _____________
Total Yearly Excludable Unearned Income
$ _____________
Total Yearly Countable Unearned Income
$ _____________
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SSA Records Interview
10. Earned Income
Beneficiary
None
Wages: $ _______ SEI : $ _______
Amounts decreased: Yes No
Stopped or plans to stop work? Yes No When? _________
Work expenses? Yes No
Computer Match: $_________
Living-with Spouse
None
Wages: $ _______ SEI : $ _______
Amounts decreased: Yes No
Stopped or plans to stop work? Yes No When? _________
Work expenses? Yes No
Computer Match: $_________
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Date last worked: Beneficiary _______ Spouse_________ Date plans to stop work: Beneficiary _______ Spouse_________
Beneficiary Living-with Spouse
Wages $_________ $_________ NESE $_________ $_________ Sheltered Workshop Earnings $_________ $_________ Royalties $_________ $_________ Honoraria $_________ $_________ In-Kind Earned Income $_________ $_________
Source Name: _____________________________________ Address : _____________________________________ _____________________________________ Phone : ( ) ____________________
Source Name: _____________________________________ Address : _____________________________________ _____________________________________ Phone : ( ) ____________________
Explanation of decrease in earnings: ___________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ Work Expenses
IRWE/BWE Yes No
Type(s): _______________________________________
Amount: $____________
Frequency: Weekly Monthly Yearly
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Verification Conclusion
10. Earned Income and Earned Income Exclusions
None Earned Income established: See employer contact in file See systems query (DEQY, SEQY) See SSA-4201 See tax return See copy of other business record See summary of beneficiary’s/living-with Spouse’s records (i.e. pay stubs) Collateral contact made: Source: ____________________________________ ____________________________________ ____________________________________ Date of Contact: ___________ Finding: ____________________________________ _____________________________________
Source: ____________________________________ ____________________________________ ____________________________________ Date of Contact: ___________ Finding: ____________________________________ ____________________________________
Earned Income Exclusion established per HI 03020.ff:
Type: ______________ Amount: $__________ Type: ______________ Amount: $__________ Type: ______________ Amount: $__________
Work Expense(s) established:
IRWE BWE
Type: __________________________
Amount: $____________
Frequency: Weekly Monthly Yearly
Findings: ____________________________________________ ____________________________________________________
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Neither Beneficiary nor Living-with Spouse has Earned Income
Beneficiary has yearly Earned Income of: $ _____________
Living-with Spouse has yearly Earned Income of: $ _____________
Total Yearly Earned Income: $___________
Total Earned Income Exclusion: Type: ____________ Amount:$_________
Work Expense(s):
IRWE BWE: $ _____________
Total Yearly Countable Earned Income: $___________
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Total Yearly Countable Income Summary
In Kind Support and Maintenance: $ ___________
Unearned Income: $ ___________
Earned Income: $ ___________
Total $ ___________ |
No deficiency
Deficiency: _________________
Income caused ineligibility or affected the Subsidy Level:
Yes No
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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.
Medicare Subsidy-Quality Review Case Analysis
SSA-9301 (04/2007)
| File Type | application/msword |
| File Title | MEDICARE SUBSIDY - QUALITY REVIEW CASE ANALYSIS |
| Author | 364490 |
| Last Modified By | SME |
| File Modified | 2007-08-13 |
| File Created | 2007-08-13 |