TN 15 (09-17)

HI 03050.030 Initial and Cyclical Redeterminations Process for Extra Help

A. Case selection for initial Extra Help redeterminations

The system evaluates the Initial Extra Help redetermination cases selects some for initial redeterminations in August every year. The selection criteria includes beneficiaries, both individuals and couples, who became eligible from May of the prior year through April of the selection year.

For example, the initial redetermination process completed in August 2014 selected from beneficiaries who became eligible from May 2013 through April 2014. The System selects these beneficiaries for an initial redetermination if they have not already had a subsidy-changing event (SCE) or Other Event reported between May and December of 2013. SSA uses agency data in all cases.

The beneficiary selected for an initial redetermination will receive an SSA-1026-OCR-SM-REDE (Social Security Administration Review Of Your Eligibility For Extra Help). The selection criteria include:

  1. Cases where agency data indicate a potential change in Extra Help;

  2. Beneficiaries who reported an Other Event between January and the redetermination selection date in August;

  3. Beneficiaries who did not respond to an Office of Quality Review (OQR) report finding during the review period;

  4. Beneficiaries whose records had errors OQR found during the OQR review;

  5. Members of a couple who have different Extra Help filing dates, different Extra Help levels, or a spouse who reported an SCE; and

  6. Cases that fall into the category of special outreach, if any, for the year.

NOTE: SSA excludes anyone who CMS deems eligible for Extra Help, previously reported an SCE, or had a no-error OQR result.

B. Case selection for cyclical Extra Help redeterminations

SSA selects cyclical redeterminations annually in August.

The selection for cyclical redetermination includes:

  • Extra Help-eligible beneficiaries who are more likely to have a change in the Extra Help amount, e.g., cases where agency data indicates a potential change in subsidy;

  • Members of a couple with different Extra Help filing dates or different Extra Help levels;

  • Beneficiaries that reported an Other Event;

  • Surviving spouses;

  • Beneficiaries who did not respond to an OQR finding during the review period; and

  • Beneficiaries for whom OQR found errors on the record during the OQR report findings.

C. Extra Help redeterminations for couple cases

If System selects both members of a couple for a redetermination:

  • SSA mails only one SSA-1026-OCR-SM-REDE.

  • If one member of a couple returns the SSA-1026-OCR-SM-REDE and the information on the form does not match the information already in the System, the Medicare Application Processing System (MAPS) will generate an exception to the servicing field office (FO). To process this action, use Question 3 (Change in marital status) instructions in HI 03050.040B.

NOTE: Since the System selected both members of the couple on one application, we close the pending redetermination (based on that one application) so that the person who returned the redetermination form can continue to process any type of future applications. The System will convert the one who returned the SSA-1026-REDE form, to an SCE report and he or she will have a subsidy based on the SCE.

  • The REDET extension on the Development Worksheet screen (DWMP) will close with a report date equal to the receipt of the application.

  • If the other member of the couple (who did not return the SSA-1026-REDE form) does not report an SCE, or if we do not receive an SCE report from Medicare Miscellaneous Update Data Exchange (MUDEX) or the Railroad Board (RRB) data exchange, he or she will continue the current subsidy level until the next redetermination cycle or report of an SCE.

NOTE: SSA mails an SSA-1026-OCR-SM-SCE form to the surviving spouse if we identify a death during the redetermination selection process and an SSA-1026-OCR-SM-SCE has not yet been mailed. In situations where one member of the couple died between redetermination selection and the processing of the returned SSA-1026-REDE, MAPS will generate a household composition exception to the FO stating: “MBR indicates applicant is deceased” or “MBR indicates spouse is deceased.” The exception language is based on which member of a couple is deceased. For FO instructions in this situation, see HI 03050.025C.5. and HI 03050.025C.6.

D. Processing the SSA-1026-REDE form

Beneficiaries are required to complete the SSA-1026-OCR-SM-REDE form and return it to WBDOC within 30 days. The beneficiary may contact SSA within the 30-day period to request a one-time extension, not to exceed 30 days.

1. SSA-1026-REDE form returned within 30 days

The following occurs when the beneficiary returns the redetermination form within the prescribed period:

  1. The technician scans the form into MAPS.

  2. If the scanning process indicates the change is an SCE, the case is sent to the FO for processing. For processing instructions for SCEs, see HI 03050.025B through HI 03050.025C.

  3. If the scanning process indicates the change is a result of an Other Event or there is no change, the case will follow the Subsidy Determination process, subject to exception or verification as needed.

  4. If the redetermination results in a change, that is material to the Extra Help determination and the redetermination form is returned by November 30, the effective date of the change will be January of the following year.

    NOTE: If the beneficiary returns a redetermination form after November 30 of the year the redetermination form was mailed, the effective date of change is the first day of the second month following the month the form is returned. For example, a redetermination form returned in December will be effective February 1 of the following year.

  5. If the return of the cyclical redetermination results in an SCE, any change in subsidy level is effective the month after the month of the report of change.

2. Beneficiary does not return the SSA-1026-REDE form within 30 days

If the beneficiary does not return, the form within 30 days or at the end of any extension, we will terminate the Extra Help after due process notice is provided for failure to return the form.

E. Process for Medicare Reminder System (MRS) and SSA-2708 (Come-In/Call-In Letter) follow up

In mid-November, the vendor who handles the Medicare Reminder System (MRS) makes follow-up telephone calls to beneficiaries who failed to return the SSA-1026 on time and reminds them to complete and return the SSA-1026 (Statement for Continuing Eligibility for Extra Help with Medicare Prescription Drug Plan Costs) in order to retain eligibility for the Extra Help.

1. Automated SSA-2708 sent to beneficiaries with invalid telephone number

After the vendor completes the calls, the New York Regional Office (NYRO) sends an automated SSA-2708 (Field Office Call/Come In Request) to beneficiaries that MRS could not successfully contact and beneficiaries for whom Systems could not provide a valid telephone number. The SSA-2708 contains language requesting the beneficiary contact their servicing FO the end of January to complete a redetermination for Medicare Part D Extra Help.

2. Non-responders with a special notice option (SNO)

In addition, the NYRO posts the names and Social Security numbers (SSNs) of beneficiaries who are non-responders and have the Special Notice Option (SNO) in their agency records to the New York Medicare Follow-up website. These names and SSNs appear on the website for the servicing FO under “Action Type of CCYY (the current year will be displayed) Redeterminations Not Received-SNO ONLY”. FOs will create the SSA-2708 within the Document Processing System (DPS) and select the SNO option. For detailed FO instructions, see HI 03050.030F in this section. The NYRO does not generate an automated SSA-2708 for beneficiaries with SNO indicators in their agency records.

NOTE: The FOs no longer place follow-up phone calls to beneficiaries who do not complete and return the SSA-1026, including beneficiaries with SNO indicators in their agency records.

F. FO instructions for Extra Help redeterminations

The SSA-2708 contains language requesting the beneficiary to contact his or her servicing FO by the end of January to complete a redetermination for Medicare Part D Extra Help. The SSA-2708 also provides:

  1. Information about interpreter services;

  2. Information about SSA’s toll-free number and TTY services; and

  3. The telephone number and address of their servicing FO.

1. Responding to SSA-2708 inquiries

If the beneficiary calls or visits the FO in response to a manual or automated SSA-2708 regarding the redetermination for Medicare Part D Extra Help:

  1. Explain the law requires that SSA periodically re-determine a beneficiary’s continuing eligibility for and the level of Extra Help.

  2. Inform the beneficiary that you can help him or her in completing the redetermination. If you do complete the redetermination at that time, complete it in MAPS.

  3. Remind the beneficiary to complete and return the SSA-1026 no later than January 31 (if you do not complete the redetermination in MAPS) or his or her Extra Help will terminate March 31.

For processing Extra Help redeterminations see HI 03050.025 through HI 03050.040.

NOTE: FOs must complete these cases by mid-February. Central Office (CO) will release a final notice to non-responders at the end of February.

2. Beneficiaries with SNO-Action Type “SNO ONLY” indicated on the NYRO website

When the names and SSNs appear on the NYRO website for the servicing FO under “SNO-Action Type of CCYY Redeterminations Not Received-SNO ONLY”, take the following actions:

a. Query MAPS to determine if the beneficiary completed and returned the SSA-1026 redetermination form.

  1. If the beneficiary completed and returned the SSA-1026 form, access the Intranet Application Case Processing Screen on the New York Medicare Follow-up website and choose “Completed Redetermination” from the “Processing Results” drop down list. Click the “Update Result” button before exiting the website.

  2. If MAPS shows the beneficiary as “Deemed Eligible” for the new year, access the Intranet Application Case Processing Screen on the New York Medicare Follow-up website and choose “Deemed Beneficiary for (new year)” from the “Processing Results” drop down list. Click the “Update Result” button before exiting the website. No other action is necessary for these beneficiaries.

b. If the beneficiary is not deemed eligible for Extra Help for the new year and did not return the SSA-1026, send a notice to the beneficiary.

  1. Enter DPS and create a SSA-2708 informing the beneficiary that he or she needs to call or come in to the FO by the end of January to complete a redetermination for Medicare Part D Extra Help.

  2. Access the New York Medicare Follow-up website and annotate the notice action. No further action is necessary.

NOTE: FO employees do not make follow-up phone calls and only annotate the New York Medicare Follow-up website for non-responders with SNO in SSA records.

G. National 800 Number Network (N8NN) Instructions for Extra Help redeterminations

If you receive an inquiry from a beneficiary regarding the Extra Help redetermination form, follow the instructions in TC 24020.090.

H. Taking an SSA-1020 instead of the SSA-1026

If the beneficiary com