Addendum for Medicare Quality Review System (OMB No. 0960-0707)

FOR FORMS SSA-9301, -9302, -9303, -9304, -9308, -9310,

-9311, -9312,- 9313, -9314 -8510

MEDICARE SUBSIDY QUALITY REVIEW FORMS

20 CFR 418(b)(5)

OMB No. 0960-0707

ADDENDUM TO THE SUPPORTING STATEMENT

Below are SSA’s proposed changes to three forms from the Medicare Quality Review System. We are making these changes to comply with the provisions of Public Law 110-275, the Medicare Improvements for Patients and Providers Act of 2008. Specifically, the law modifies Part D Subsidy eligibility criteria by disregarding In-Kind Support and Maintenance (ISM) and Life Insurance policy face value as assets.

SSA-9301 (Medicare Subsidy-Quality Review Case Analysis)

Page 4

We removed the In-Kind Support and Maintenance (ISM) question and its contents. We moved the questions regarding Average Monthly Household Expenses to Page 4, which we re-named Family Size.

Rationale:

We now disregard ISM when determining eligibility for LIS. We moved the Average Monthly Household Expenses questions to Family Size (we still need this information to determine of one-half support is met).

Page 5

We removed the ISM question and re-named the questions “Family Size.”

Rationale:

We disregard ISM when determining eligibility for LIS. The Average Monthly Household Expenses questions were moved to Family Size. This information is still needed to determine if one-half support is met.

Page 6-7

We re-named these pages “Liquid Resources.”

Rationale:

We re-named these pages due to the deletion of the ISM question.

Pages 8-9

We re-named these pages “Non-Home Real Property.”

Rationale:

We now disregard life insurance when determining eligibility for LIS, so we re-named the pages to reflect the remaining questions.

Pages 10-11

We removed the reference to life insurance policy. We re-named this to Funeral/Burial Funds and Total Countable Resources Summary.

Rationale:

We re-named this page due to the deletion of the life insurance question in compliance with P.L. 110-275.

Pages 12-13

We re-named this “Unearned Income.”

Rationale:

We re-named this page due to the deletion of the life insurance question in compliance with P.L. 110-275.

Pages 14-15

Re-named to “Earned Income.”

Rationale:

We re-named this page due to the deletion of the life insurance question in compliance with P.L. 110-275.

Page 16

We re-named this to “Total Yearly Countable Income Summary and Remarks/Deficiency Analysis.”

Rationale:

We re-named this page due to the deletion of the life insurance question in compliance with P.L. 110-275.

Page 17

We renamed this page to “Remarks/Deficiency Analysis (continued)”

Rationale:

We re-named this page due to the deletion of the life insurance question in compliance with P.L. 110-275.

SSA-9304 (Checklist of Required Information)

We removed from C. Resource bullet 4, the Life insurance paragraph.

Rationale:

We now disregard life insurance policy face value when determining eligibility for the Part D subsidy.

Form SSA-9309 (Life Insurance Verification)

We are discontinuing use of this form.

Rationale:

As per P.L. 110-275, we no longer count the face value of life insurance policies as assets when determining eligibility, so there is no need for us to verify life insurance value.

0960-0707 Addendum

12/10/2008

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