Identification Number:
HI 03050 TN 23
Intended Audience:See Transmittal Sheet
Originating Office:ORDP OISP
Title:Redeterminations
Type:POMS Full Transmittals
Program:Medicare
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part HI – Health Insurance

Chapter 030 – Eligibility for Subsidized Medicare Prescription Drug Coverage

Subchapter 50 – Redeterminations

Transmittal No. 23, 01/31/2024

Audience

PSC: BA, CA, CS, DS, IES, ILPDS, IPDS, ISRA, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, CR, CTE, EIE, ERE, FCR, FDE, PETL, RECONE, RECONR;
Subsidy Appeals Unit (SAU): SDR, SDS, SDT;
OCO-ODO: BET, BTE, CCE, CR, CST, CTE, CTE TE, DEC, DES, PAS, PETE, PETL;
FO/TSC: CS, CS TII, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

OISP

Effective Date

Upon Receipt

Background

This transmittal provides new policy to support the legislative changes mandated in the Inflation Reduction Act of 2022 (IRA), Section 11404, which expands Medicare Part D Extra Help (Low-Income Subsidy or LIS) full subsidy and ends Extra Help partial subsidy effective January 1, 2024.

Summary of Changes

HI 03050.015 Adjustments and Terminations

Subsection A: Added language about IRA change.

Subsection B: Corrected cross outdated POMS references and minor grammatical updates to improve clarity.

Subsection C: Corrected outdated POMS references.

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

Subsection A: Added language about IRA change and corrected outdated hyperlink.

Subsections E & F: Corrected outdated POMS references.

Revised this section as part of the Inclusive Language Initiative.

HI 03050.025 Subsidy-Changing Event (SCE) and Other Event

Subsection A: Removed subsidy amount language.

Subsection B:

  • Added language about IRA change.

  • Corrected outdated POMS references.

Subsection C:

  • Removed subsidy amount language.

  • Corrected outdated POMS references and hyperlinks.

Subsection D:

  • Removed subsidy amount language.

  • Corrected outdated POMS references.

Revised this section as part of the Inclusive Language Initiative.

HI 03050.030 Initial and Cyclical Redeterminations Process for Extra Help

Subsection A:

  • Removed Extra Help level language.

  • Added language about IRA change.

  • Corrected outdated hyperlinks.

Subsection B:

  • Removed Extra Help level language.

  • Added language about IRA change.

Subsection C: Corrected outdated hyperlink.

Subsections D & F: Removed subsidy level language.

Subsection H: Corrected outdated hyperlink.

Revised this section as part of the Inclusive Language Initiative.

HI 03050.015 Adjustments and Terminations

A. INTRODUCTION

There are no mandatory reporting rules in the Extra Help program. An Extra Help beneficiary or any person, company, or agency may contact SSA to report a change in income, resources, or household composition. This section explains the effect of eligibility changes in Medicare Part D Extra Help (low-income subsidy or LIS) eligibility.

Starting January 1, 2024, the Inflation Reduction Act (IRA) provides full subsidy to all eligible Extra Help beneficiaries. Extra Help applications that have a coverage start date before January 1, 2024 may result in a partial subsidy award. To locate the coverage start date field in MAPS, see MS 03301.008C [11-D]. For applications that have not been set to subsidy determination, locate the field in MAPS that captures estimated effective date, see MS 03206.002.E [21-D].

 

NOTE: 

This section does not explain how to evaluate Extra Help program reports of change. Those instructions appear in HI 03050.025. For instructions on how to correct technician identified errors within 60 days of initial determination or hearing, see HI 03050.045.

B. POLICY

1. Subsidy-Changing Events

Certain changes in an individual’s circumstances could increase or reduce a subsidy amount or terminate eligibility for a subsidy. The six subsidy-changing events are listed in HI 03050.025.

NOTE: 

Starting January 1, 2024, the Inflation Reduction Act (IRA) provides full subsidy to all eligible Extra Help beneficiaries. Extra Help applications that have a coverage start date before January 1, 2024 may result in a partial subsidy award. To locate the coverage start date field in MAPS, see MS 03301.008C [11-D]. For applications that have not been set to subsidy determination, locate the field in MAPS that captures estimated effective date, see MS 03206.002.E [21-D].

2. Increase in Subsidy

An increase in a subsidy amount means that an individual would be able to pay a lower premium to participate in the Medicare Part D program. An increase in subsidy may also result in a reduction in or elimination of any deductible. In certain situations, an increase in a subsidy amount may result in a reduced copayment for covered prescription drugs for which an individual is responsible.

3. Reduction in Subsidy

A reduction in a subsidy means that an individual would have to begin to pay a premium or a higher premium to participate in the Medicare Part D program. The individual may also have to begin to pay a deductible and in some cases a higher copayment for covered prescription drugs.

4. Termination of Subsidy

A termination means that an individual would no longer be eligible for a subsidy under the Medicare Part D program.

NOTE: After a termination, an individual must generally file a new application (absent a favorable appeal decision) and meet the requirements in HI 03001.020 to qualify for a subsidy. See an exception in HI 03010.005D for an individual who subsequently qualifies as a deemed eligible person.

5. Effective Dates

Adjustments and terminations will be effective beginning in January of the next calendar year following a periodic redetermination or the month after the month of the report of a change that is a subsidy changing event as defined in HI 03050.025. Individuals must receive an advance written notice of intent with the effective date of the adjustment or termination which includes their appeal rights. Appeal rights for a reduction or termination will include the right to continue to receive a subsidy at the established level until there is a decision on the appeal. These procedures are explained in detail in HI 03040.001.

C. REFERENCES

  • HI 03001.020 Eligibility for Extra Help (Prescription Drug Low-Income Subsidy)

  • HI 03010.005 Interviewing for Medicare Part D Extra Help

  • HI 03040.001 Overview of Appeals Process for Medicare Part D Subsidy

HI 03050.000 Redeterminations

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).

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.

A change in income, resources, or household composition can affect a beneficiary’s eligibility for Extra Help and the subsidy eligibility.

The Inflation Reduction Act (IRA) provides full subsidy to all eligible Extra Help beneficiaries who have a coverage start date on or after January 1, 2024. To locate the coverage start date field in MAPS, see MS 03301.008C [11-D]. For applications that have not been sent to subsidy determination, locate the field in MAPS that captures the estimated effective date (see MS 03206.002E [21-D]).

B. Four types of Extra Help redeterminations

There are four types of LIS redeterminations:

  1. 1. 

    Redeterminations due to an SCE;

  2. 2. 

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

  3. 3. 

    Initial Redeterminations; and

  4. 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. The beneficiaries 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 deemed status through the calendar year even if they lose eligibility for the program on which their deemed status is based (i.e., the beneficiaries become ineligible for SSI, Medicaid and/or the MSP). If the beneficiary is deemed eligible for Extra Help because of SSI-eligibility, 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 the beneficiaries are 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. The individual 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 the individual 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. The individual 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 mid-November, the vendor who handles the Medicare Reminder System (MRS) makes follow-up telephone calls to beneficiaries who failed to return the SSA-1020 (Application for Extra Help with Medicare Prescription Drug Plan Costs) and reminds them to complete and return the SSA-1020 in order to retain eligibility for the Extra Help.

If beneficiaries contact SSA regarding the Extra Help application included with the notice, the FO must post results to the NYRO Medicare Follow-up website. National 800 Number Network (N8NN) staff and Workload Support Unit (WSU) claim takers do not document the website regarding calls from beneficiaries wishing to file for Extra Help.

E. Reports of change of address

For Title II beneficiaries, process a change of address report immediately via the Postentitlement Online System (POS) screen as shown in MS 06303.001. This will update the address on the beneficiary's Master Beneficiary Record (MBR). The Medicare database uses the MBR address. If the beneficiary also receives Title XVI benefits, follow normal Title XVI procedures for processing the change of address. For Title II and Title XVI change of address policy and procedures see GN 02605.000 and SI 02306.010.

F. References

GN 02605.000 Processing Change of Address

HI 03040.001 Overview of Appeal Process for Medicare Part D Subsidy Determination

HI 03050.025 Subsidy-Changing Event (SCE) and Other Event

HI 03050.030 Initial and Cyclical Redeterminations Process for Extra Help

HI 03050.035 Extra Help Redetermination Forms

HI 03050.040 Exception Processing for Form SSA-1026 Questions

MS 06303.001 Maintenance Event Screens - Overview

SI 02301.000 SSI Posteligibility Changes

SI 02306.010 Change of Address or Residence

HI 03050.025 Subsidy-Changing Event (SCE) and Other Event

A. Reporting events that may affect the Extra Help determination and subsidy eligibility

A change in income, resources, or household composition can affect a beneficiary's eligibility for Extra Help. Reporting events or changes that may affect a beneficiary’s Medicare Part D Extra Help determination or subsidy eligibility differs from Title II and Title XVI event and change reporting in three ways:

  1. 1. 

    Medicare Extra Help beneficiaries are not required to report changes.

  2. 2. 

    There is no distinction between how first- and third-party reports are processed.

  3. 3. 

    There are two types of events that can affect the Extra Help determination or subsidy eligibility:

    1. a. 

      Subsidy Changing Events (SCEs), as defined in HI 03050.025B, and

    2. b. 

      Other Events, which are events that may change the Extra Help determination or subsidy eligibility, such as a change in income, resources, or household composition.

The type of event determines how Medicare Application Processing System (MAPS) processes the report and the effective date of any change in subsidy eligibility.

NOTE: Policy for Medicare Part D Extra Help does not supersede existing Title II and Title XVI policy. Process a report of change that may also affect Title II and Title XVI benefits according to the established policy for those programs. For post eligibility factors, policies, and procedures see GN 02600.000 (Title II) and SI 02300.000 (Title XVI).

 

B. Description of an SCE

There are six SCEs:

  1. 1. 

    Marriage,

  2. 2. 

    Death of living-with spouse,

  3. 3. 

    Divorce from living-with spouse,

  4. 4. 

    Annulment from living-with spouse,

  5. 5. 

    Separation from living-with spouse, and

  6. 6. 

    Resumption of living together with previously separated spouse.

SCEs may affect the beneficiary’s eligibility.

When the technician enters the report of the SCE in the MAPS via the Changing Event screen, the system sends an Extra Help redetermination form (SSA-1026-OCR-SM-SCE) to the beneficiary for completion.

After entering the SCE report on the screen and mailing the SSA-1026-SCE, the action stays pending in Management Information (MI) Central for the office that entered the report (Teleservice Center (TSC) or Field Office (FO)) until the SCE form is returned or the Extra Help terminates.

Alternately, the Claims Specialist (CS) in the FO can complete the redetermination immediately in MAPS. For additional information and an example regarding FO completion of an SCE report see HI 03050.025C.3.

If the report results in a change to the subsidy eligibility, the system will issue the appropriate notice. The Notice of Change, Notice of Planned Action, and Notice of Termination give appeal rights.

1. Effective date of an SCE

With the exception of some living-with spouse death reports, a change in Extra Help because of an SCE will be effective the month after the month the report is received and entered into MAPS provided the beneficiary returns the completed redetermination form within 90 days (the date of the form is specified in the form’s bar code). If the beneficiary returns the form within 90 days, we will take one of three actions based on the responses on the SSA-1026-OCR-SM-SCE (Statement for Continuing Eligibility for Extra Help with Medicare Prescription Drug Plan Costs):

  • Increase or decrease the Extra Help amount;

  • Terminate the Extra Help; or

  • Determine no change in the Extra Help is necessary.

We will discuss how we decide which action to take later in this section.

NOTE: 

The Inflation Reduction Act (IRA) provides full subsidy to all eligible Extra Help beneficiaries who have a coverage start date on or after January 1, 2024. Extra Help applications that have a coverage start date before January 1, 2024 may result in a partial subsidy award. The amount of Extra Help may vary on partial subsidy awards. For more information about partial subsidy amount categories, see HI 03035.010C. To locate the coverage start date field in MAPS, see MS 03301.008C [11-D]. For applications that have not been sent to subsidy determination, locate the field in MAPS that captures the estimated effective date (see MS 03206.002E [21-D].

2. SCE form is not returned within 90 days

If the beneficiary who has an SCE does not return the Extra Help redetermination form within 90 days, the Extra Help termination is effective the first month following the end of the 90-day period. The beneficiary may contact the FO within the 90-day period and request a 30-day extension. Technicians may grant only one extension and that extension must not exceed 30 days. Select the “Redetermination Extension Issue” on the Development Worksheet Main screen (DWMP) in MAPS and add 30 days. For detailed instructions for adding a 30-day extension, see MS 03206.002   and MS 03206.018  .

If the beneficiary returns the SSA-1026-OCR-SM-SCE after 90 days, but before the termination of the Extra Help has been processed, process the SCE. If we receive the SSA-1026-OCR-SM-SCE after 90 days and due process notification was sent to the beneficiary, treat the form as an appeal. For appeals processing, see HI 03040.000.

NOTE: If the beneficiary calls or visits the FO and is ready to complete the Extra Help redetermination the day of the report, refer to instructions on MAPS processing in HI 03050.025E and HI 03050.025G.

C. Procedure when a beneficiary reports an SCE

When the beneficiary contacts SSA and reports an SCE, use the Changing Event screen in MAPS to record the SCE. For instructions on completing an SCE redetermination or report go to HI 03050.025C.3. in this section. Completing the Changing Event screen in MAPS will update the Medicare database and prompt the system to mail an Extra Help redetermination form to the beneficiary for completion.

1. SCE reports received by the National 800 Number Network (N8NN) staff

If a beneficiary reports an SCE to the N8NN staff, follow the instructions in TC 24020.080E.

REMINDER: If the caller is reporting a marriage and the new spouse is Extra Help eligible, be sure to ask the caller if the report is also for the spouse.

If the caller reported a marriage and is reporting for both members of the couple, be sure to enter the SCE on both records in MAPS to mail an SSA-1026-OCR-SM-SCE to each member of the couple. Each member of the couple must return their form.

EXAMPLE 1: Beneficiary reports a divorce

Bill Jones calls the N8NN in February 2014 to report a divorce from a live-in spouse. The technician should document this SCE on the Changing Event screen in MAPS. Bill is not ready to complete the form immediately. The agent inputs the SCE in MAPS via the Changing Event screen to issue a SSA-1026-OCR-SM-SCE redetermination form to Bill. MAPS will recalculate the Extra Help amount. If Bill returns the form within the 90-day period, any changes to Medicare Part D Extra Help will be effective March 2014.

EXAMPLE 2: Beneficiary reports a marriage

Mary Smith, a beneficiary, contacts SSA in May 2014to report a change in the household composition due to marriage starting March 2014. This is an SCE. Mary says there is no time to provide the necessary information immediately. The N8NN will take the following actions:

  • Input the event on the Changing Event screen in MAPS, which generates a redetermination form.

  • Ask Mary if the spouse is also eligible for Extra Help.

  • If the spouse is eligible for Extra Help, ask if Mary is reporting the change for the spouse as well.

  • If Mary is reporting the change for the spouse, enter an SCE for the spouse. The spouse also will receive a redetermination form.

Each member of the couple must return the redetermination form even though the information collected on each form should be identical. If we receive the forms within the 90-day period with the updated income and resource information, we will process them in MAPS and the system will then determine the new Extra Help eligibility. The effective date of change will be June 2014 for Mary and the new spouse.

2. SCE reports made to N8NN staff during the appeals period

Some beneficiaries may call during the appeals period to report an SCE. Follow these guidelines when beneficiaries call during the appeals period:

If the caller contacts the N8NN during the appeals period and…

The N8NN Staff will:

Has been denied Part D Extra Help...

Establish an appeal.

Has been awarded the subsidy and reports an SCE…

Process the SCE per the instructions for processing an SCE in HI 03050.025C.1. in this section.

Disagrees with the Extra Help determination and reports an SCE…

Establish the appeal. Annotate the case to show the beneficiary reported an SCE and note that the Subsidy Determination Reviewer (SDR) needs to process the SCE after the appeal determination.

The SDR will be responsible for both the appeal and processing the SCE. The SDR should process the SCE upon completion of the appeal.

3. SCE reports received in the FO

If a beneficiary visits or contacts a FO and reports an SCE, take the following steps:

  1. a. 

    Input the event via the Changing Event screen. (For instructions on completing the event, see MS 03206.014 .)

  2. b. 

    Select “Take New MAPS Application For” to complete the MAPS screens for the SCE.

  3. c. 

    Submit the SCE redetermination to the Subsidy Determination Process.

  4. d. 

    Be sure to complete any forms and inputs needed to update the Title II and Title XVI systems when appropriate.

  5. e. 

    Advise the beneficiary that the change will be effective the month after the month of report or at least one year from the month following the month of the report if the event involves the death of a beneficiary’s living-with spouse and the surviving spouse meets the requirements described in HI 03050.025C.5.

NOTE: If one member of the couple does not report an SCE, or if no SCE report is received from the Medicare Miscellaneous Update Data Exchange (MUDEX) or the Railroad Board data exchange, the other member of the couple will continue their current subsidy award until the next redetermination cycle.

4. Beneficiary reports a marriage to the FO

If the beneficiary contacts the FO to report a marriage, take the following steps:

  1. a. 

    Ask if the new spouse is also an Extra Help beneficiary.

  2. b. 

    Ask the beneficiary if the report also is for their spouse, if the new spouse has Extra Help.

  3. c. 

    Enter the updated information into each of the MAPS records showing each beneficiary as married and living together.

REMINDER: Take any appropriate Title II and Title XVI actions associated with the marriage report.

5. Beneficiary reports the death of a living-with spouse

We will not immediately change the subsidy in situations where:

  • a beneficiary’s living-with spouse dies;

  • we have not received a report of another event that would affect the beneficiary’s Extra Help determination or amount; and

  • the death of the beneficiary’s living-with spouse would cause a decrease in or elimination of the beneficiary’s Extra Help.

If the surviving spouse meets all these conditions, we will defer the redetermination for one year from the month following the month we are notified of the death of the spouse.

NOTE: Only defer the redetermination of the Extra Help amount and eligibility in the event that the “beneficiary’s living-with spouse dies.” After we defer a redetermination for this reason, if we receive a report about another SCE or if we need to make a manual correction, we will not defer any resulting changes not due to the spouse’s death. For information regarding the manual correction process, see HI 03050.045.

6. Process for reports of the death of a living-with spouse

The Extra Help determination system will automatically send an SCE Form SSA-1026-OCR-SM-SCE (Statement for Continuing Eligibility for Extra Help with Medicare Prescription Drug Plan Costs) to a surviving spouse when we receive a spousal death report. This will allow the surviving spouse to get a timely adjustment to Part D Extra Help and results in fewer exceptions to the field requiring a conversion from an SSA-1026-REDE to an SSA-1026-SCE .

In addition, SSA will mail an SSA-1026-OCR-SM-SCE form to a surviving spouse if we identify the 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 will be based on which member of a couple is deceased.

FOs should convert the redetermination to an SCE and process it using the current information of the surviving spouse. Verify current income and resources for the surviving spouse. Income or resources may have stopped or changed with the death of the spouse.

7. Reports made to Title II

A beneficiary may report a change to SSA and fail to inform us that the change also applies to Extra Help. If the reported change is an SCE, MUDEX will update the Medicare Database. This will prompt MAPS to mail an Extra Help redetermination form (SSA-1026-OCR-SM-SCE) to the beneficiary for completion.

Example of an SCE:

Helen Mabry goes into the FO and reports the death of a spouse. The CR does not check for Medicare Extra Help eligibility. The CR processes the death report through POS. MUDEX reads the updated MBR and updates the Medicare Database. The system will mail an Extra Help redetermination form to Helen.

8. Beneficiary reports more than one SCE

MAPS must process SCEs one at a time. In some instances, a beneficiary may report two SCEs within a short time frame. If the beneficiary reports two SCEs, the first report must be processed to completion before action is taken on the second report.

EXAMPLE 1: Beneficiary reports more than one SCE

Carol Jones calls the FO on March 21, 2014 to report a change in household composition due to separation from the spouse. Carol doesn't have time to complete the update. The CS keys this on the Changing Event screen and mails an SSA-1026-OCR-SM-SCE to Carol for completion. Carol calls again on April 17, 2014 to report that they are now living together again.

The CS will take the following actions:

  1. a. 

    Record this information about the second report and annotate the Development Worksheet (DWMP) screen.

  2. b. 

    When the beneficiary returns the SSA-1026-OCR-SM-SCE for the first report, process it to completion.

  3. c. 

    When the first report is completed, process the second SCE using the same procedure, beginning with the input on the Changing Event screen.

The first report will affect the April subsidy. The second event, which was reported in April, will affect the May subsidy.

EXAMPLE 2: Beneficiary reports more than one SCE in a short timeframe

Harry Calish contacts the N8NN on March 2, 2014 to report a change in household composition due to separation from the spouse. Harry is unable to complete the update at that time. An SCE form is mailed out to Harry. Harry calls back on March 19, 2014 to report that they are back together. Harry has not returned the SSA-1026-OCR-SM-SCE.

Since the self-cancelling events both occurred in the same month, the CS takes the following actions:

  • Cancel the SCE by removing the posted event from the “Changing Event” screen found at the top of the Development Worksheet (DWMP) screen. Removing the event cancels the update and deletes the 90-day termination diary;

  • Advise Harry not to return the SSA-1026-OCR-SM-SCE; and

  • Complete a Report of Contact outlining the reason for cancelling the SCE.

D. Description of Other Event redeterminations

Events other than the six SCEs may also result in the recalculation of the Extra Help eligibility, but not until a redetermination is completed. We select Other Event cases for redeterminations beginning in August and MAPS mails notices in early September of each year.

EXAMPLE: Beneficiary reports a change in his household

William Brown calls in June 2014. William reports that the household size has increased. The SSA employee will take the following actions:

  • Access the Changing Event screen (DWCE) in MAPS and select “OTHER Changing Event” from the drop-down menu of type of events.

  • Explain to William that SSA will mail an SSA-1026-OCR-SM-REDE redetermination form which should be received sometime around the end of August.

  • Instruct William to include the information about the changes in the household on the redetermination form.

  • Explain to William that the completed form must be returned within 30 days.

1. Other Event reports received between January and August

If a beneficiary reports a change other than an SCE between January and the redetermination selection date in August, input the Changing Event screen (DWCE) and the system will send an SSA-1026-OCR-SM-REDE with the cyclical redeterminations sent in August of each year (as described in section HI 03050.030).

For reports of Other Events, the N8NN staff will follow the instructions in TC 24020.080E.

EXAMPLE: Beneficiary reports stop work and change in income

Carl Jones contacts SSA in February 2014 to report a work stoppage and has no other income besides Title II benefits. Although this may change the amount of Extra Help received, this is not one of the six SCEs. The N8NN agent, Customer Service Representative (CSR), or CS will input the event on the Medicare database. SSA mails a redetermination form, SSA-1026-OCR-SM-REDE, to Carl in August.

2. Other Event reports received August through December

If the person reports an Other Event in August through December, the report will immediately generate an SSA-1026-OCR-SM-REDE to the beneficiary. As a result:

  1. a. 

    The beneficiary must return the form to WBDOC within 30 days of the date on the form.

  2. b. 

    The beneficiary may contact the N8NN or FO within the 30-day period to request a one-time extension, not to exceed 30 days.

  3. c. 

    If the redetermination results in a change material to the subsidy level or eligibility, and the beneficiary returns the form by November 30, the effective date of the change will be January of the following year.

    NOTE: A redetermination form returned after November 30 of the year we mailed the form is effective 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 upcoming year.

  4. d. 

    If the beneficiary does not return the form in the prescribed time, we terminate the Extra Help after due process notice is provided for failure to return the form.

    REMINDER: Policy for Medicare Part D Extra Help does not supersede or replace existing Title II or Title XVI policy or procedures. We process any report of change that will also affect Title II or Title XVI benefits according to the established policy and procedures for those programs.

E. Processing reports of SCEs or Other Events

If a beneficiary reports one of the six SCEs listed in HI 03050.025B or Other Events reported between August and December that could affect the subsidy level or eligibility, such as a change in income, resources, or household composition, follow the procedures in the chart in HI 03050.025G.

NOTE: Reports of Other Events made in January through the redetermination selection date in August are part of the cyclical process.

F. Procedure for N8NN staff instructions for SCEs or Other Events reported in August through December

Instructions for N8NN staff to process SCE and Other Event reports reported in August through December are in TC 24020.080

G. Procedure for FO instructions for SCE or Other Event reported in August through December

When the beneficiary calls, visits, or schedules an appointment with the FO to report an SCE or Other Event, take the following actions:

Step

Action

1

The FO conducts a redetermination using MAPS.

2

Upon completion of the redetermination and any necessary development, the FO will:

  • Submit the information to Subsidy Determination in MAPS for re-evaluation of Extra Help eligibility;

  • If appropriate, use the date that the N8NN appointment screen was completed as the date of the report; and

  • Inform the beneficiary/personal representative to dispose of the redetermination form because the FO has completed the redetermination.

SSA sends an automated notice to the beneficiary with the result of the redetermination.

This ends the redetermination process. No other action is necessary.

3

If MAPS refers the redetermination to the FO to resolve an issue, the FO resolves the issue(s) and submits the resolution to Subsidy Determination in MAPS. Subsidy Determination allows the Medicare Database (MDB) to re-evaluate the Extra Help eligibility and subsidy level, and then generates an automated notice to the beneficiary with the result of the redetermination.

For a description of the verification process, see HI 03035.000.

NOTE: In some cases, the beneficiary or personal representative contacts the FO to report an event but is unable to give much information about income, resources, or household composition. Start the redetermination based on the information the beneficiary or personal representative provides. Then, obtain information needed to complete the redetermination review.

H. Procedure for Extra Help redetermination forms returned to WBDOC

When the Extra Help redetermination forms are returned to WBDOC, follow the actions in the below table.

Step

Action

1

The individual returns the form in the enclosed postage-paid envelope to the WBDOC.

2

WBDOC scans the SSA-1026-OCR-SM-SCE or the SSA-1026-OCR-SM-REDE.

3

WBDOC rekeys any necessary data and electronically forwards the data and image to Central Office. WBDOC completes exception processing, as needed. If an issue needs resolution, WBDOC refers the redetermination to the servicing FO. For processing exceptions, see HI 03050.040.

I. References

  • HI 03035.000 Verification Process and Pre-Decisional Issues

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

  • HI 03050.030 Initial and Cyclical Redeterminations Process for Extra Help

  • HI 03050.040 Exception Processing for Form SSA-1026 Questions

  • HI 03050.045 Manual Correction Process for the Extra Help Application

  • HI 03040.000 Appeal of Medicare Part D Subsidy Determination

  • TC 24020.080 Handling Post Entitlement Reports That May Affect the Subsidy

HI 03050.030 Initial and Cyclical Redeterminations Process for Extra Help

A. Case selection for initial Extra Help redeterminations

In August of every year, SSA systems identify initial Extra Help awards and randomly selects cases for initial redeterminations. The selection criteria includes beneficiaries, both individuals and couples, who became eligible from May of the prior year through April of the selection year.

Example: The initial redetermination process completed in August 2023 are selected from beneficiaries who became eligible from May 2022 through April 2023. The System selects these beneficiaries for an initial redetermination if the beneficiaries have not already had a subsidy-changing event (SCE) or Other Event reported between May and December of 2022. SSA uses agency data in all cases.

Example: Beneficiaries 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. 1. 

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

  2. 2. 

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

  3. 3. 

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

  4. 4. 

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

  5. 5. 

    Members of a couple who have different Extra Help filing dates, different Extra Help eligibility determinations, or a spouse who reported an SCE; and

  6. 6. 

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

    NOTE: 

    On August 16, 2022, the President signed the Inflation Reduction Act (IRA) of 2022, Public Law 17-169. Section 11404 expands full subsidy eligibility and ends what is currently known as partial subsidy eligibility. Starting January 1, 2024, only subsidy cases with subsidy determination effective dates before January 1, 2024 can receive partial subsidy awards. For applications that have not been sent to subsidy determination, locate the field in MAPS that captures the estimated effective date, see MS 03206.002E.[21-D].To locate the coverage state date field in MAPS, see MS 03301.008C. [11-D]. For information about MAPS determination dates, see MS 03206.021.

IMPORTANT: 

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 include:

  1. 1. 

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

  2. 2. 

    Members of a couple with different Extra Help filing dates or different Extra Help eligibility determinations;

  3. 3. 

    Beneficiaries that reported an Other Event;

  4. 4. 

    Surviving spouses;

  5. 5. 

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

  6. 6. 

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

SSA redetermination selections exclude anyone who CMS deems eligible for Extra Help, previously reported an SCE, or had a no error OQR result.

NOTE: 

On August 16, 2022, the President signed the Inflation Reduction Act (IRA) of 2022, Public Law 17-169. Section 11404 expands full subsidy eligibility and ends what is currently known as partial subsidy eligibility. Starting January 1, 2024, only subsidy cases with subsidy determination effective dates before January 1, 2024 can receive partial subsidy awards. For applications that have not been sent to subsidy determination, locate the field in MAPS that captures the estimated effective date, see MS 03206.002E.[21-D].To locate the coverage state date field in MAPS, see MS 03301.008C. [11-D]. For information about MAPS determination dates, see MS 03206.021.

C. Extra Help redeterminations for couple cases

If the 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 the one member 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, the member will continue the current subsidy determination 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. a. 

    The technician scans the form into MAPS.

  2. b. 

    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. c. 

    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. d. 

    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. e. 

    If the return of the cyclical redetermination results in an SCE, any change in subsidy eligibility 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 by 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 the servicing FO by the end of January to complete a redetermination for Medicare Part D Extra Help. The SSA-2708 also provides:

  1. a. 

    Information about interpreter services;

  2. b. 

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

  3. c. 

    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. a. 

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

  2. b. 

    Inform the beneficiary that you can help with completing the redetermination. If you do complete the redetermination at that time, complete it in MAPS.

  3. c. 

    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 the 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. 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. 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. 1. 

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

  2. 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 completes a new Extra Help SSA-1020 (Application for Extra Help with Medicare Prescription Drug Plan Costs) instead of form SSA-1026 (Statement for Continuing Eligibility for Extra Help with Medicare Prescription Drug Plan Costs), MAPS software will allow the processing of form SSA-1020.

Beneficiaries can still complete form SSA-1026 through March 31st .

I. References

  • HI 03035.000 Verification Process and Pre-Decisional Issues

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

  • HI 03050.025 Subsidy-Changing Event (SCE) and Other Event

  • HI 03050.040 Exception Processing for Form SSA-1026 Questions

  • HI 03050.045 Manual Correction Process for the Extra Help Application


HI 03050 TN 23 - Redeterminations - 1/31/2024