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
Remarks:
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Other Contact:
Representative Payee (if applicable)
Name: ________________________
Address: _______________________
_______________________
Phone: ( ) ______________
Third Party
Name: ________________________
Address: ________________________
________________________
Phone: ( ) ______________
Remarks |
SSA Records Interview
1. Identity
SSN: Beneficiary: _______________
Living-with Spouse: _______________
Date of Birth
Beneficiary: __________________
Living-with Spouse: __________________ Remarks: __________________ 2. Marital Status
Single, Divorced, Widow(er), Married Not Living-with Spouse
Married Living- with Spouse
Remarks:
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SSN agrees with systems queries
Beneficiary Living-with Spouse
_________________ Name on Record ____________________ _________________ Date of Birth ____________________ _________________ Birthplace ____________________ _________________ Parents ____________________ _________________ ____________________
_______________ SSN ____________________
Remarks
________________________________________________________ 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: __________________
Remarks |
Verification Conclusion
1. Identity verified:
Beneficiary: Yes No
Living-with Spouse: Yes No
Remarks |
No deficiency
Deficiency ___________________ ___________________ ___________________
Remarks:
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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 __________________ __________________ __________________
Remarks:
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SSA Records Interview
3. Family Size (FS)
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: ____
Remarks:
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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. (In none, proceed to conclusion column for completion.)
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 $_______
Remarks |
Verification Conclusion
3. Family Size 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.
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 $______
Collateral Contact:
Name: _________________________ Address: _________________________ _________________________ _________________________ Phone: ( ) _____________ Findings: ______________________________________ ______________________________________
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No deficiency
Deficiency: ______ ___________________ ___________________ ___________________ ___________________
Remarks:
Total FS:__________
Difference Yes No
Stand Alone Deficiency Yes No
Combined Deficiency Yes No
___________________ ___________________ ___________________ ___________________
Remarks:
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SSA Records Interview
4. Liquid Resources
None
Bank Accounts: $______
Stocks, bonds, savings bonds, mutual funds, IRA or similar accounts: $______
Cash: $______
Other:_____________ __________________
$_______
Computer Match: $_______
Remarks:
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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
4. 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: $______________
Remarks
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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 __________ ______________________ ______________________ ______________________
Remarks:
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SSA Records Interview
5. Non-home Real Property
Ownership:
Yes No
CMV $ _________
Remarks:
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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: ______________________________________ ___________________________________________________
Remarks |
Verification Conclusion
5. Non-Home Real Property
Allegations verified by:
Government records
Tax Assessment Statement Insert New Text Here Other (i.e. deed, sales contract, etc.) __________________
Collateral contact made:
Name of Source: _______________________________ Address: ______________________________________ Owner(s): ______________________________________ Verified CMV: $__________ Equity Value: $__________
Insert Text Name of Source: _______________________________ Address: ______________________________________ Owner(s): ______________________________________ Verified CMV: $__________ Equity Value: $___________
Encumbrances: _______________________________________ _____________________________________________________ _____________________________________________________
Property Essential for Self-Support: $______
Remarks:
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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: _________ ______________________ ______________________ ______________________
Remarks:
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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
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Verification Conclusion
6. Funeral/Burial Funds Add Text
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Exclusion does not apply
Exclusion applies
Beneficiary only
Living-with Spouse only
Both
No deficiency
Deficiency: _________________ Remarks: |
Total Countable Resources Summary
Type of Resource Total Value
Liquid Resources $ ___________
Non-Home Real Property $ ___________
Subtotal $___________
Minus Burial Fund Exclusion $___________ (If applicable)
Total $ ___________
Add Text |
No deficiency
Deficiency: _________________
Resources caused ineligibility or affected the subsidy level:
Yes No
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SSA Records Interview
7. Unearned Income
Beneficiary
None
Income type: ____________
Amount: $ ______
Income type: ____________
Amount: $ ______
Computer Match: $______
Living-with Spouse
None
Income type: __________________
Amount: $ _________
Income type: __________________
Amount: $ _________
Computer Match: $_______
Remarks:
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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
7. 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: $__________
Remarks:
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Total Yearly Unearned Income
$ _____________
Total Yearly Excludable Unearned Income
$ _____________
Total Yearly Countable Unearned Income
$ _____________
Remarks:
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SSA Records Interview
8. 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: $_________
Remarks:
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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
Remarks
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Verification Conclusion
8. 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: $___________
Remarks:
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Total Yearly Countable Income Summary
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 1
Form SSA-9301 (04-2007)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | MEDICARE SUBSIDY - QUALITY REVIEW CASE ANALYSIS |
| Author | 364490 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |