HA is in total offset 06/1996 ($0.00 payable).
HA $33.10 payable - Due to 12/1998 statutory (COLA) increase.
36.10 payable - Due to 01/1999 redetermination increase.
3.00 difference - Enter this amount on the line 2B, along with the COLA of 33.10
Enter the total increase of 36.10 in Part 1, line I.
Go back to Part 1 Line I.
Part 1 Line I. - Sum of all protected increases in Part 2
Enter in Line I only those protected increases shown in Part 2 (line B) including protected increases for HA and all auxiliaries (made prior to, and including the latest redetermination).
Part 1 Line J. - Unprotected balance payable
Subtract line I (protected increases) from line G (total benefits payable after offset) and enter this amount. Do not enter an amount less than zero.
Return to Part 2 line C.
Part 2 Line C. Total (HA increases only)
Enter the total of all HA increases (statutory and redetermined).
Part 2 Line D. Total of Part 1 Line J and Part 2 - Line C.
Add the total of unprotected balance payable (1.J.) and HA increases (2.C.) and enter that amount in Part 2, line D.
Part 2 Line E. - Amount payable to HA
Part 1 line H is the number holder’s PIA. If the amount in line H equals or exceeds Part 2 line D, pay amount in 2D to HA, otherwise pay amount in 1H to HA (the lower of 1H or 2D will be the HA payable). This amount is the sum computed before protected increases occurring after the redetermination. If there were protected increases after the last redetermination, add the increases after the redetermination and before the change in WC/PDB. This brings the rate up to the rate payable at that point.
Part 2 Line F. - Amount payable to the auxiliary
Subtract line E from line D and enter the difference in line 2F. Do not enter an amount less than zero.
Part 2 Line G. - Divide by number of auxiliaries
Enter the number of auxiliaries in the first column.
Divide line F by the number of auxiliaries.
Enter this amount under the Part 2 line G columns for all auxiliaries (whose BICs are listed).
Part 2 Line H. - Total to auxiliaries
Add all protected increases in Part 2, line B and Part 2, line G for each auxiliary. Do not include HA increases.
Enter this total for each auxiliary BIC that is listed. This sum is the amount before protected increases occurring after the redetermination. If there were protected increases after the last redetermination, add the increases after the redetermination and before the change in WC/PDB. This brings the rate up to the rate payable at that point.
Signature and date
Sign and date the form. Then, scan or fax into the claims folder.
Completing the back of the SSA-2454
Use the back of the SSA-2454 to manually prorate lump sum settlement awards or other calculations (e.g., WC/PDB mid-month adjustments, etc.).