HI 03035: Verification Process and Pre-Decisional Issues
TN 21 (04-13)
Applications go to the verification process when the comparison of application data and agency data for income does not fall within certain tolerances.
For additional instructions for income verification, follow instructions in HI 03035.006.
A. Policy on income tolerances for application and agency data comparison
We base the income tolerances on the income limits for Extra Help eligibility. We compute income limits from the Federal Poverty Level (FPL) using the FPL percentages (135%, 140%, 145%, and 150%) required by law and the Department of Health and Human Services (HHS) regulations.
For Extra Help eligibility requirements and current income limits, see HI 03001.005 and HI 03020.055.
B. Sources of agency data for income
We obtain agency data regarding income from the following sources:
Master Beneficiary Record (MBR)
Railroad Retirement Board (RRB)
Department of Veterans Affairs (VA)
Office of Personnel Management (OPM)
Office of Child Support and Enforcement (OCSE)
Internal Revenue Service (IRS)
C. Subsidy (Extra Help) categories
To be eligible for a particular Medicare Part D subsidy category (i.e., 100%, 75%, 50%, 25%), the applicant’s income must be within the range of income for that category. For a chart that illustrates the current FPLs and corresponding Medicare Part D premium subsidy by family size, see HI 03001.020C.3.
To determine if the applicant’s countable income is within a given subsidy category, count both earned and unearned income.
D. When MAPS require verification and when it is not
Using the Medicare Part D subsidy categories in HI 03035.010C in this section, we compare application data for income with data from other agencies. The application data on the Medicare Application Processing System (MAPS) verification screen is the applicant’s allegation of earned and unearned income on the Extra Help application. The agency data consists of the earned and unearned income from data matches with other agencies. The system applies the following rules to determine if we must verify the application.
1. MAPS requires verification
MAPS sends the application through verification if:
the application data indicates less income than the agency income data and,
the difference in the income amounts result in a change from one subsidy category to another.
EXAMPLE: Ms. Wallace files for Extra Help. Her total countable income (application data) for the applicable period is $15,500 (more than 100% and less than 135% on the 2018 FPL table for a family size of one). The agency data from data matching indicates income of $16,789 (more than 135% and less than 140% on the 2018 FPL table for a family size of one).
Because the application data falls in the 100% premium subsidy category and the agency data falls in the 75% premium subsidy category, MAPS will send the application to verification.
2. MAPS does not require verification
MAPS does not send the application to verification if:
the application data and agency data both indicate income within the same subsidy category, and the system determines full or partial subsidy;
the application data and agency data both indicate income above the income limit for Extra Help eligibility (the system automatically issues a pre-decisional notice);
the application data indicates higher income than the agency data;
the application data indicates lower unearned income than the agency data, but the applicant answered the question about a recent unearned income decrease affirmatively (Question 10 on the SSA-1020-OCR, Application for Help with Medicare Prescription Drug Costs); or
the application data indicates lower earned income than the agency data, but the applicant answered the question about a recent earned income decrease affirmatively (Question 14 on the SSA-1020-OCR).
EXAMPLE: Mr. James files for Extra Help. His total countable income (application data) for the applicable period is $16,300 (more than 135% and less than 140% on the 2018 FPL table for a family size of one). The agency data from data matching indicates income of $16,880 (more than 135% and less than 140% on the 2018 FPL table for a family size of one).
Because both the application data and the agency data fall within the 75% premium subsidy category, MAPS will not send this application to verification.
E. Procedure for verifying income
Follow these procedures when verifying income:
NOTE: Under Public Law (P.L.) 110-275 (The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)), in-kind support and maintenance (ISM) is not countable as income for Extra Help applications filed January 1, 2010, or later. Although MAPS does not select ISM as a verification issue, the claims representative (CR) may identify ISM as a development issue while processing another verification issue (e.g., the applicant reported income incorrectly on the application). When a CR needs to develop further, he or she counts ISM for Medicare Part D Extra Help applications effectively filed December 31, 2009 or earlier. If the applicant files an Extra Help application January 1, 2010 or later, do not count ISM. MAPS will not use ISM in the computation of countable income.
See Also:
HI 03035.006, for additional instructions on verifying income.
1. Query the Medicare database and contact the applicant
The Medicare System Query displays data from the Medicare database. The verification screen clearly identifies income from the RRB, VA, and OPM. The verification screen does not show the specific source of the agency data for the income fields “Other Pensions or Annuities” and “Other Unearned Income.” For information on verifying “Other Unearned Income” or “Other Pension or Annuities” income posted on MAPS verification screen (VRAI), see HI 03035.010D in this section and HI 03035.010G in this section.
For instructions on verifying pension and annuity income, see HI 03035.012.
To obtain detailed agency data, access the Detailed Agency Data (DADS) screen by clicking on the “Query” option on the verification screen.
Contact the applicant after you review the Medicare database. If you make contact with someone other than the applicant, use caution to avoid improper disclosure. When contacting the applicant:
Discuss the discrepancy between the application data and the agency data. For instructions on if the applicant dies before we process the Extra Help application, see HI 03010.010E.
Discuss each type of income with a dollar amount posted in either the “Application” or “Agency” data field of the VRAI.
Obtain the applicant’s explanation for discrepancies between the income amounts posted in the “Application” and “Agency” data fields.
Accept the explanation and determine that the application data is the correct amount for the application data income if the applicant provides a reasonable explanation for the application data.
NOTE: When verifying an IRS reported pension or annuity, see HI 03035.012.
Inform the applicant that we will use the agency data for the Extra Help determination if the applicant agrees with the agency data.
Inform the applicant that we will use the agency data for the Extra Help determination unless he or she provides evidence to the contrary if the applicant is not able to provide a reasonable explanation for the discrepancy. To offer assistance for evidence and closeout, see HI 03010.040.
Assist the applicant in determining the actual amount of the excludable work expenses and input the determined amount if the applicant indicates that his or her actual work expenses are higher than the amount automatically posted by MAPS as impairment-related work expenses (IRWE) or blind work expenses (BWE), see HI 03020.030.
NOTE: The applicant must meet the requirements for IRWE or BWE for the system to post an excluded amount.
2. Verify the “Stop Work Date”
When the CR performs verification for earned income:
Verify with the applicant that the “Stop Work Date” alleged on the application is correct. If it is not correct, input the correct “Stop Work Date” on the appropriate MAPS screens. Based on the “Stop Work Date” MAPS determines the months for countable earnings. An incorrect date results in incorrectly counting the applicant’s earned income, which can result in an erroneous subsidy determination.
Input the correct “Stop Work Date” on the MAPS Work Stop Date and Work Expenses for Disability (ATWE) screen for initial applications, or the State Agency Work Sampling (SAWS) screen for redeterminations prior to submitting the case for a Medicare Part D Subsidy Determination. If the applicant has ongoing earned income from the filing date, delete the “Stop Work Date” in MAPS.
Document the determination to revise or delete the “Stop Work Date” when completing the MAPS Report of Contact (DWRC).
3. Document first-time homebuyer and deemed first-time homebuyer tax credit
On November 6, 2009, the President signed the Worker, Homeownership and Business Assistance Act of 2009 (WHBA), which extends the deadline for receiving a tax credit for purchasing a home under the American Recovery and Reinvestment Act of 2009 (ARRA). WHBA also established a smaller tax credit, up to $6,500, for homebuyers who lived in their principal residence five out of the last eight years and purchased a new principal residence. For purposes of eligibility for the tax credit, these applicants are “deemed” first-time homebuyers.
For Medicare Part D Extra Help purposes, consider the first-time homebuyer’s and deemed first-time homebuyer’s tax credit as countable unearned income. By law, we do not exclude the first-time homebuyer’s tax credit or the deemed first-time homebuyer’s tax credit when we determine eligibility for Medicare Part D Extra Help.
NOTE: For more information on counting the first-time homebuyer’s and deemed first-time homebuyer’s tax credit as a resource, see the Supplemental Security Income instructions in SI 01130.676C.3.
4. Verify the $250 economic recovery payment from the American Recovery and Reinvestment Act of 2009 (ARRA)
When verifying the $250 economic recovery payment:
Verify income for Medicare Part D Extra Help applications filed May 2009 through December 2010. If the applicant reports other income on the application, ask the applicant if he or she received a $250 payment based on the ARRA of 2009.
Exclude one-time ARRA payments of $250 from income to determine Medicare Part D Extra Help eligibility.
Inform the applicant not to report ARRA payment as income on the application for Medicare Part D Extra Help. If the applicant reported funds as income, the field office (FO) must correct the applicant’s income on the verification screen accordingly.
5. Document the making work pay tax credit from the ARRA
The Making Work Pay Tax Credit provides working applicants a reduction in the amount of income tax withholding deducted from their pay checks. This tax credit increases the applicant’s take home pay, but does not increase the applicant’s gross wages.
For purposes of determining eligibility for Medicare Part D Extra Help, the increase in take home pay is not countable as income. This includes situations where the applicant has an increase in take home pay from multiple employers.
Applicants with very low wages may not receive their full tax credit through an increase in take home pay. Self-employed applicants do not receive this tax credit in take home pay. These applicants can get the tax credit as part of a tax refund when they file their income tax return. If the applicant receives a tax credit in his or her tax refund, exclude it from income for Medicare Part D Extra Help.
You do not need to take special action because the increase in take home pay does not affect the computation of countable earned income, based on the applicant’s gross wages.
NOTE: We do not exclude the $25 weekly ARRA unemployment compensation increase from income or resources in States that agree to participate in this program. You do not need additional documentation or development verification.
See Also:
HI 03020.050 for more information on the one-time $250 payment, the $25 per week unemployment compensation increase, and the Making Work Pay Tax Credit.
HI 03030.020 for information on the resource exclusions for the one-time $250 payment and the Making Work Pay Tax Credit.
HI 03035.020 for resource verification.
6. Verify the Filipino Veterans Equity Compensation Fund payment
ARRA establishes the Filipino Veterans Equity Compensation Fund (FVECF) that provides a one-time payment for veterans who served in the Philippine armed forces during World War II. Only a small number of applicants will receive this payment, however, some veterans who file for Medicare Part D Extra Help may require verification via MAPS.
Eligible veterans who are citizens of the United States (U.S.) may receive a one-time payment of $15,000. Eligible veterans who are non-U.S. citizens may receive a one-time payment of $9,000. A veteran’s surviving spouse may receive the one-time payment only if the veteran filed for, but did not receive the payment prior to death.
When verifying receipt of FVECF:
Exclude the one-time FVECF payment from income to determine Medicare Part D Extra Help eligibility received by the veteran or the surviving spouse.
Accept the Medicare Part D Extra Help applicant’s allegation about the receipt of this special payment and the amount of the payment.
Inform the Medicare Part D Extra Help applicant not to report the FVECF payment as income on the application for Medicare Part D Extra Help. If the applicant incorrectly reported funds as income, the FO must correct the applicant’s income on the verification screen accordingly.
If the applicant incorrectly reported funds, correct the income amounts on the income verification screen as income and document the verification on the (DWRC) screen.
NOTE: Direct all public inquiries related to applying or obtaining eligibility requirements to the Department of Veterans Affairs Office at 1-800-827-1000 or under “Locations.” On their website: http://www.va.gov/..
For more information about income exclusions for Medicare Part D Extra Help, see HI 03020.050.
For more information about resource exclusions for Medicare Part D Extra Help, see HI 03030.020.
7. Verify payment from the Economic Stimulus Act of 2008
When verifying income for Medicare Part D Extra Help applications filed May 1, 2008 through December 31, 2009, and the applicant reports other income on the application:
Ask the applicant if he or she received a payment based on the Economic Stimulus Act of 2008. Explain to the applicant not to report the stimulus payment as income on the application for the Extra Help; and
If the applicant incorrectly reported funds as income, the FO must correct the applicant’s income on the verification screen accordingly.
NOTE: Although distribution of the stimulus payments was completed December 31, 2008, the applicant may not receive a payment issued December 2008, until January 2009. Possibly, an applicant filing for Extra Help during 2009 might report the stimulus payment as other income; adjudicators must ask about these payments while doing verifications for claims filed through December 31, 2009.
8. Document the verification determination
Document the verification determination following procedures in HI 03035.007.
Use the DWRC screen to document:
verified income amounts;
types of evidence reviewed;
FO determination (Resolved or Failure to Cooperate); and
dates and types of contacts made.
NOTE: Document the type of contacts made on the DWRC screen by inputting the name of the person you contacted, dates, and a brief summary of the discussion (e.g., Workers’ compensation stopped in 04/07; application data is correct).
REMINDER: Do not photocopy evidence for the file because you must record all documentation on the verification screens.
9. Input the verification determination
Input the verification determination as follows:
Select “None,” “Application,” “Agency,” or “New Amount” on the VRAI screen to indicate the correct amount of income for each type of income under consideration.
If the applicant reports income not already on the application, input that in the appropriate field.
When all income issues are resolved and there are no items marked “Not Verified,” go to the “Issue Resolution” section, select the “Resolved” button, and click on “Submit to Subsidy Determination.”
If you made two unsuccessful attempts to contact the applicant by phone and the applicant does not respond to the Evidence Request Notice within the 15-day closeout period, input “failure to cooperate” and click on “submit to subsidy determination.” For additional information on evidence and closeout, see HI 03010.040.
F. Procedure for garnished Title II benefits
If we show the applicant’s benefit amount as garnished, MAPS does not reflect the full countable Title II benefit amount; and MAPS does not allow correction of the Title II benefit amount. If you discover a situation during verification where the Title II amount is incorrect due to garnishment, add the difference (i.e., the amount garnished) to the income amount, if any, posted in the “Other Unearned Income” field and explain the situation on a DWRC screen. If you are speaking with the applicant or spouse at the time of the verification, explain the situation to him or her. Although the applicant's Income and Resource Summary is not completely accurate, base the determination on the correct income.
Use the full MBR (FACT) query to determine the amount of garnished Title II benefits. The dates and amounts of garnishment are in the GARNISH and the Deductions Additions History (DED/ADD) data lines of the FACT query.
For the GARNISH data line, see SM 00510.397.
For the DED/ADD data line, see SM 00510.584.
G. Procedure for “other unearned income” reported on MAPS verification screen
The DADS screen does not provide detailed agency data for unemployment benefits reported by OCSE. The OCSE agency data available in MAPS shows on the Current Agency Data Screen in MAPS as “Unemployment (OCSE).”
If the applicant reports “Other Unearned Income” and corresponding “Unemployment (OCSE),” and no detailed agency data is present, determine that the other unearned income is unemployment benefits and that the source of the unemployment is the applicant’s State of residence.
H. How to process the application for “Other Unearned Income”
1. Query MAPS current agency data screen
If you select an application for verification that has “Other Unearned Income” reported and the DADS screen has no corresponding detailed agency data, query the MAPS Current Agency Data screen to see if the undocumented unearned income lists as “Unemployment (OCSE).”
2. Develop and document unemployment income
If there is a report of “Unemployment (OCSE)” on the MAPS Current Agency Data screen, develop and document the unemployment income following the procedures in HI 03035.010E in this section.
3. Develop and document other unearned income
If the applicant’s other unearned income remains unexplained, develop and document the remaining unearned income following the procedures in HI 03035.010, in this section.
REMINDER: The unexplained “Other Unearned Income” could be the amount of garnished Title II benefits (see HI 03035.010F in this section). For instructions on verifying annuity income, see HI 03035.012.
I. OPM annuity income reported in MAPS
Prior to May 23, 2009, MAPS received OPM annuity data from OPM and IRS. Effective with the Medicare software release on May 23, 2009, we updated the MAPS database with the pension data received only from OPM to avoid possible double counting of an OPM pension. You may view previous entries of OPM and IRS data remaining on the database through the Medicare Query System (MEDQ) on the “Detailed Agency Data” screen. The annuity data that comes from OPM displays on the Current Agency Data screen as “OPM/Civil Service” and on the VRAI screen as “Other Pensions or Annuities.”
J. References
HI 03001.005 Medicare Part D Extra Help (Low Income Subsidy or LIS)
HI 03010.010E Filing Applications
HI 03010.040 Information/Evidence and Closeout
HI 03020.030 Earned Income Exclusions
HI 03020.055 Income Limits for Subsidy Eligibility
HI 03035.005 Verification Policy within the Medicare Application Processing System (MAPS)
HI 03035.006 Verification and Documentation Process for Medicare Application Processing System (MAPS)
HI 03035.007 Verification and Documentation Instructions for Internal Revenue Service (IRS) data within the Medicare Application Processing System (MAPS)
HI 03035.008 Chart with IRS Transaction Types for the Medicare Application Processing System (MAPS During the Verification Process
GN 02410.200 Garnishment
MSOM INTRANETMEDQ 001.008 Medicare Query Display (QDIS) – Part D (Prescription Drug Plan) Data View
MSOM INTRANETMEDQ 001.009 Detailed Agency Data Screen (DADS)
MSOM INTRANETMAPS 006.006 MAPS Development Worksheet – Issue Verification (VRAI)