A claimant or personal representative acting on the claimant’s behalf (see HI 03010.010B) must file a valid application to become eligible for the subsidy. EXCEPTION: Deemed claimants who meet the criteria in HI 03010.005D do not have to file an application. Rather, The Centers for Medicare and Medicaid Services (CMS) will send SSA a file on deemed eligibles. This information is then updated to the Medicare Application Processing System (MAPS).

In accordance with the HHS’ regulation 42 CFR 423.772, a proper applicant to file a subsidy application is a claimant or a claimant's personal representative.

A personal representative is defined as:

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  An individual who is authorized to act on behalf of the claimant;

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  Someone who is acting responsibly on the claimant’s behalf because the claimant is incapacitated, or incompetent; or

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  An individual of the claimant’s choice who is requested by the claimant to act as the claimant's representative in the application process.

The claimant or the claimant's personal representative will complete and sign the application for the subsidy using the Social Security Administration (SSA) alternative signature proxy methods. Signature proxy replaced the traditional pen-and-ink signature for applications and other claims-related processes (see GN 00201.015 for the policy and procedures for using signature proxies). SSA will assume that the application is completed by an authorized person. There is no need to determine if a proper applicant filed the application. In addition, there is no formal representative payee process applicable with the subsidy.

IMPORTANT: The fact that a person is acting as a personal representative does not mean that SSA can disclose information to that person from SSA’s records. See GN 03305.001 regarding disclosure to third parties.

The subsidy application is called “Application for Help with Medicare Prescription Drug Plan Costs” and is not an application for any other program benefit administered by SSA to which the claimant may be eligible to receive. The application, however, is a protective filing for Supplemental Security Income (see HI 03010.020A).

The subsidy application will remain pending until SSA makes a final decision on it. A determination will not become final until the appeal period expires or a decision on any appeal filed on a subsidy determination (e.g., a request for appeal on the calculation of income and resources) is issued to the claimant. See HI 03040.001C.1. for ways to request an appeal. If a claimant meets all the requirements for the subsidy (except for enrollment in a Part D or MA-PD plan) and is in an enrollment period at the time of filing the application or before we make a final decision, the claimant will be sent a notice about their eligibility for the subsidy and will be advised of the need to enroll in a Prescription Drug Plan or a Medicare Advantage Prescription Drug Plan. Otherwise, if the claimant cannot be enrolled in Part A or B because the claimant is not in an enrollment period, the subsidy application will be denied. If the individual is in an enrollment period but does not enroll in a plan, CMS will select and enroll the individual in a plan at the end of their enrollment period.

If the individual is not entitled to Medicare Part A and/or enrolled in Medicare Part B and does not have Medicare coverage through the Railroad Retirement Board (RRB) but is in an enrollment period at the time the application for the subsidy is processed through Subsidy Determination, the record will be held in a conditional status until the individual files for Medicare. A notice will be sent to the individual which states that SSA will not make a determination until the individual become entitled to Part A and/or enrolled in Part B. Once the individual files for Medicare, the system will issue the award or pre-decisional notice. If the claimant does not become entitled to Medicare Part A and/or enroll in Medicare Part B before the first redetermination is scheduled, the record will be denied and the individual must file a new application for extra help and become entitled to Medicare Part A and/or enroll in Medicare Part B during a subsequent enrollment period. See HI 03001.001J for Part D enrollment periods and HI 00805.010, HI 00805.015, and HI 00805.025 for Medicare Part B enrollment periods.

If the individual is not entitled to Medicare Part A and/or enrolled in Medicare Part B at the time the application is filed and is not in an enrollment period, SSA will deny the application and send the individual a notice. The notice will include appeal rights and inform the individual that they are not eligible for the subsidy because they are not entitled to Medicare Part A and/or enrolled in Medicare Part B.

If the claimant is alive on the first day of the month in which the subsidy application is filed, but dies before SSA processes it, a subsidy eligibility determination is required from the filing date month through the month of death, if the information obtained shows the claimant was enrolled in a PDP. If the claimant was not enrolled in a PDP in the month the application was filed, and dies in that month, the application should be canceled.

In a couple’s case, if one member of the couple dies before the application is processed but the deceased spouse was enrolled in a PDP in the month of filing, a subsidy eligibility determination is required from the filing date month through the month of death. The deceased spouse’s income is used to determine the living spouse’s subsidy for the month of filing through the month of the deceased spouse’s death. If the deceased spouse was not enrolled in a PDP in the month of filing and subsequently dies in that month, an eligibility determination is not required. The couple’s application should be canceled and an individual application should be created for the living spouse. Since enrollment in a PDP could not occur before the next month, determining the deceased spouse’s LIS eligibility would not be necessary.

When verification is required:

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  Contact the third party, if one is named on the subsidy application to resolve the verification issue.

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  If the third party is unresponsive or unable to reconcile the discrepancy, contact the living with spouse, if one is named on the subsidy application.

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  If neither is named or the named third party/spouse cannot reconcile the discrepancy, use Agency data to make the determination.

Follow the procedures in HI 03035.006C. and HI 03035.006C.1. when contacting the third party and/or a living with spouse named on the application, with the exception of the last bullet in HI 03035.006C.2. Agency data will be used, if the contacts are unsuccessful or there is no one to contact.

EXCEPTION: A subsidy determination is not required if death occurred before:

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  1/2006, or

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  The effective date of Part D enrollment. Policy - Subsequent Applications