TN 15 (09-17)

HI 03050.020 Redetermination of Eligibility for Medicare Part D Extra Help (Low-Income Subsidy)

A. Background for LIS redeterminations

Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), requires the Social Security Administration (SSA) to periodically review a beneficiary’s continuing eligibility for Medicare Part D Extra Help and the amount of Extra Help (also known as low-income subsidy, LIS, or subsidy). A change in income, resources, or household composition can affect a beneficiary’s eligibility for Extra Help and the subsidy amount.

Each year in August, SSA systems select beneficiaries who receive Extra Help and meet the criteria for an Extra Help redetermination. SSA mails these beneficiaries an SSA-1026-OCR-SM-REDE (Social Security Administration Review Of Your Eligibility For Extra Help).

SSA mails Extra Help beneficiaries who experience a Subsidy-Changing Event (SCE) an SSA-1026-OCR-SM-SCE .

We instruct beneficiaries to complete the SSA-1026 form and return it to the Wilkes-Barre Direct Operations Center (WBDOC) for processing. For additional information regarding timeframes for returning an SSA-1026 form see HI 03050.025B.2. and HI 03050.030D.

B. Four types of Extra Help redeterminations

There are four types of LIS redeterminations:

  1. Redeterminations due to an SCE;

  2. Redeterminations following a report of an Other Event (For definition of Other Event see HI 03050.025A);

  3. Initial Redeterminations; and

  4. Cyclical Redeterminations.

SSA makes subsidy determinations for a calendar year. The determinations will not change during the year unless the beneficiary:

  • Appeals the determination;

  • Reports an SCE; or

  • Becomes eligible for SSI, Medicaid, or the Medicare Savings Programs (MSP) and is therefore deemed eligible for Extra Help.

There are no mandatory reporting rules in the Medicare Part D Extra Help program.

Any person, company, or agency may report events that affect a beneficiary's subsidy. The source of information does not affect how the report of change is processed.

Subsidy beneficiaries are entitled to due process and can appeal the agency's determination. They may also be entitled to subsidy continuation until SSA makes a determination at the appeal level. For additional Extra Help appeal information, see HI 03040.001.

C. Reports by beneficiaries who are deemed eligible for Extra Help

Beneficiaries who are deemed eligible for Extra Help maintain that deemed status through the calendar year even if they lose eligibility for the program on which their deemed status is based (i.e., they become ineligible for SSI, Medicaid and/or the MSP). If the beneficiary is deemed eligible for Extra Help because he or she is SSI-eligible, process the SSI report. For processing beneficiary reports that can affect SSI eligibility see SI 02301.000. Changes may affect eligibility for the program through which he or she is deemed. As a result, the beneficiary should report changes directly to that program. If the beneficiary is deemed eligible for Extra Help based on Medicaid or MSP eligibility and contacts SSA to report a change, refer the beneficiary to the State Medicaid agency.

D. Beneficiary loses Extra Help deemed status because of ineligibility

A person who becomes ineligible for SSI, Medicaid, or benefits through the MSP, loses deemed status for the following calendar year. He or she will need to file an application for Medicare Part D Extra Help to be eligible for the subsidy the following calendar year. If the person contacts SSA, tell him or her that the Centers for Medicare & Medicaid Services (CMS) will send a letter later in the year, usually in September, which will include an application form. He or she should file an application at that time.

The New York Regional Office (NYRO) posts the names and SSNs of the beneficiaries receiving this notice to the NYRO Medicare Follow-up website for the servicing field office (FO) under the action type of “September CCYY (the current year will be displayed) Nondeemed Notices”. FOs do not perform follow-ups for beneficiaries who lost their deemed status for Extra Help. In