HI 03050: Redeterminations
TN 15 (09-17)
A. Introduction to the SSA-1026 Redetermination form
SSA designed the SSA-1026 (Statement for Continuing Eligibility for Extra Help with Medicare Prescription Drug Plan Costs) to allow successful scanning into the Medicare Application Processing System (MAPS). However, if an SSA-1026 form has unanswered questions, multiple responses to the same question, or illegible answers the scanner is unable to read, the data will cause an exception issue.
This section describes each question on the SSA-1026, what information will cause an exception, and the resolution for any exception.
B. Exception processing for Form SSA-1026
The Wilkes-Barre Direct Operations Center (WBDOC) and field offices (FO) will take the following designated actions to process exceptions for questions 1 through 11 and the signature/change of address page on the SSA-1026 form.
NOTE: For processing initial application exceptions, refer to HI 03010.039. For an explanation of the appropriate situations to use the ”Edit Application” function and the ”Cancel Application” function, refer to HI 03010.039H.1. and HI 03010.039H.2. You may need to use these functions to resolve some of the below exceptions.
REMINDER: In situations where one member of the couple died between redetermination selection and the processing of the returned SSA-1026-OCR-SM-REDE, MAPS will generate a household composition exception to the FO. The exception states: “MBR indicates applicant is deceased” (the applicant is deceased and the spouse is the surviving spouse) or “MBR indicates spouse is deceased” (the applicant is the surviving spouse and the applicant’s spouse is deceased). The exception language is based on which member of a couple is deceased. FOs should convert the redetermination to a subsidy-changing event (SCE) and process it using the current information of the surviving spouse. Verify the current income for the surviving spouse, i.e., income that may have stopped with the death of the spouse. Also, verify the current resources for the surviving spouse.
Question 1 – Identifying Information
The system preprints the last four digits of the SSN on the redetermination form. If the last four digits on the returned form match the last four digits of the SSN in the barcode and there are no changes to the pre-printed name, the system presumes this is the correct person and processes the redetermination.
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If… |
Then… |
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The name entered does not match the name on the barcode. |
WBDOC checks if the first name entered is a similar name or an acceptable nickname. If yes, WBDOC enters the name that is on the record, corrects other exceptions, if any, and submits it to processing. For processing instructions, see HI 03010.039F.1.a. through HI 03010.039F.1.c. If an SS-5 (Application for a Social Security Card) is required to correct the Numident, WBDOC completes a Report of Contact on the DWRC screen and transfers the case to the servicing FO. For additional details on the Report of Contact screen, see MS INTRANETMAPS 006.003. If the Numident exception was caused by “XX” in the CYD, WBDOC technicians print the entire Numident and forward it to WBDOC’s Medicare Specialist for processing. For cases other than those identified above, contact the beneficiary to obtain the correct SSN. For additional information for contacting the beneficiary see HI 03050.040C in this section. |
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The SSN does not match the SSN encoded in the bar code. |
WBDOC contacts the beneficiary to determine the correct beneficiary belonging to this action and processes it accordingly. If this results in an SCE or if the beneficiary alleges the SSN is correct, WBDOC completes a Report of Contact and transfers the case to the servicing FO. |
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The month or year of birth do not match, but the name and SSN match. |
WBDOC obtains the date of birth information from the Numident, overlays the date of birth entered with this information, corrects other exceptions, if any, and submits it to processing. If there are any XX’s in any portion of the Numident DOB field, WBDOC transfers the case to the servicing FO. |
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The person does not complete the SSN boxes. |
Assume barcode data is correct. |
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The Medicare Number is not completed. |
MAPS does not generate an exception. |
Question 2 – Identifying information for spouse
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If… |
Then… |
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The name entered does not match the name encoded in the bar code, or is not present in the MAPS data. |
WBDOC checks if the first name entered is a similar name or an acceptable nickname. If yes, WBDOC enters the name that is on the record, corrects other exceptions, if any, and submits it to processing. For processing instructions, see HI 03010.039F.1.a. through HI 03010.039F.1.c. If an SS-5 (Application for a Social Security Card) is required to correct the Numident, WBDOC completes a Report of Contact on the DWRC screen and transfers the case to the servicing FO. For additional details on the Report of Contact screen, see MS INTRANETMAPS 006.003. If the Numident exception was caused by “XX” in the CYD, WBDOC technicians print the entire Numident and forward it to WBDOC’s Medicare Specialist for processing. NOTE: For cases other than those identified above, use HI 03010.039F.2 to determine whether question 2 was erroneously completed or inadvertently skipped. For additional information for contacting the beneficiary see HI 03050.040C in this section. After all attempts to obtain the information fail, as indicated in HI 03050.040C, then WBDOC completes a Report of Contact on the DWRC screen and transfers the case to the servicing FO. The FO representative contacts the beneficiary to determine the correct information for the spouse. If the FO representative is unsuccessful, process the application for the applicant only. |
Question 3 – Change in marital status
MAPS reviews Question 3 and compares it to information provided in Question 1 and Question 2. MAPS matches this information with the information already in MAPS. If the information is the same as MAPS, the remainder of the redetermination review proceeds. If the information does not match the information already in MAPS, MAPS will generate an exception and the case is sent to the servicing FO. The FO will contact the person to determine the correct information or process an SCE.
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If… |
Then… |
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Contact the beneficiary to determine the correct information. If no change, uncheck both Married and Divorced/Widowed/Separated/Annulled boxes and continue processing. If the beneficiary indicates a change in marital status, WBDOC transfers the case to the servicing FO to process an SCE, if applicable. |
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MAPS generates an exception (“COSSN) (Client’s Own Social Security Number) does not match spouse on record”) to the servicing FO. The FO contacts the beneficiary to determine the correct information. If the spouse should remain on the record, input the spouse information, correct other exceptions, if any, and submit application for processing. If the spouse should not remain on the record, then resolve the “COSSN does not match spouse on record” exception by processing an SCE. NOTE: Do not cancel the existing pending redetermination when resolving the “COSSN does not match spouse on record” exception. If the spouse should not remain on the record, click on “Report SCE” button located on the Exception screen (EXCP) in MAPS. For additional details on the EXCP screen, see MS INTRANETMAPS 006.008. Do not enter an SCE report using the “Changing Event” button on the Development Worksheet screen (DWMP). The “Edit Application” button is not available at this time. Follow these actions to close the redetermination exception issue on the DWMP:
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MAPS generates an exception (“COSSN does not match spouse on record”) to the servicing FO. Contact the beneficiary to determine the correct information. If the spouse shown on the SSA-1026 application should be added to the record, then resolve the “COSSN does not match spouse on record” exception by processing an SCE. NOTE: Do not cancel the existing pending redetermination when resolving the “COSSN does not match spouse on record” exception. If the spouse should be added to the record, click on the “Report SCE” button located on the EXCP screen in MAPS. Do not enter an SCE report using the “Changing Event” button on the DWMP screen. The “Edit Application” button is not available at this time. Follow these actions to close the redetermination exception issue on the DWMP:
DWMP screen. NOTE: The application type changes from single to married and living together.
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OR
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MAPS generates an exception (“COSSN does not match spouse on the record”) to the servicing FO. Contact the beneficiary to determine the correct information. If the spouse shown on the SSA-1026 is the correct spouse (new spouse) then resolve the “COSSN does not match spouse on record” exception by processing an SCE. NOTE: Do not cancel the existing pending redetermination when resolving the “COSSN does not match spouse on record” exception. If the spouse listed on Question 2 is the correct spouse (new spouse), process an SCE by clicking on the “Report SCE” button located on the EXCP screen in MAPS. Do not enter an SCE report using the “Changing Event” button on the DWMP screen. The “Edit Application” button is not available at this time. Follow these actions to close the redetermination exception issue on the DWMP:
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MAPS generates an exception (“COSSN does not match spouse on record”) to the servicing FO. Contact the beneficiary to determine the correct information. If the spouse should be removed from the record, then resolve the “COSSN does not match spouse on record” exception by processing an SCE. NOTE: Do not cancel the existing pending redetermination when resolving the “COSSN does not match spouse on record” exception. If the spouse should be removed from the record, click on the “Report SCE” button located on the EXCP screen in MAPS. Do not enter an SCE report using the “Changing Event” button on the DWMP screen. The “Edit Application” button is not available at this time. Follow the actions to close the redetermination exception issue on the DWMP:
The application type will change to single. NOTE: Do not contact the former spouse to obtain an SCE redetermination. Systems will select the former spouse for a cyclical redetermination next year. If the spouse should remain on the record, enter the spouse information in Question 2, check “Married” for Question 3, correct other exceptions, if any, and submit to processing. |
Question 4 – Information correct
The question asks the beneficiary to tell us if all of the information on the Resources and Income Summary is correct.
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If... |
Then... |
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The beneficiary indicates the information on the Resources and Income Summary is correct; and The box is checked. |
MAPS ignores all other questions on the redetermination. |
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The box is not checked; and No other questions are answered on the redetermination form. |
MAPS generates an exception to WBDOC. WBDOC contacts the beneficiary to determine the correct answer. If nothing has changed, place an “X” in Question 4 and submit to processing. If there is a change in income, resources, marital status, or the number of dependent persons living in the household, answer all the questions and submit to processing. |
Question 5 – Resources
The question asks the beneficiary to tell us about any resources owned. For excluded resources, see SI 01110.210.
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If… |
Then… |
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The beneficiary indicates “no change” in the Resources and Income Summary; or The box is checked. |
MAPS ignores any other information placed in the blocks on Question 5. |
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The box is not checked; and There are no entries for individual types of resources. |
MAPS determines the information on our records is correct. MAPS does not generate an exception. |
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The box is not checked; and The image shows a money amount greater than $999999. |
Enter “999999” and submit the case to Subsidy Determination. |
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The box is not checked; and The beneficiary enters a non-numeric character as an amount. |
Contact the beneficiary to determine the correct answer. |
Question 6 – Funeral or burial funds
The question asks the beneficiary if he or she plans to use any of the resources listed in Question 5 to pay for funeral or burial expenses.
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If… |
Then… |
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The beneficiary does not check the box. |
The answer to this question defaults to “Yes” unless the beneficiary answers “No”. The “Funeral or Burial funds” question should not generate an exception. MAPS determines the information we have on our records is correct. MAPS does not generate an exception. |
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“No” is checked for “You”, “Spouse”, or both. |
MAPS does not generate an exception. |
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Total value of resources (in Question 5 or on the Medicare database) For 2018
For 2017
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MAPS does not generate an exception. MAPS processes the case as a termination. |
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Question 6 is left blank; and The total value of all resources (in Question 5 or on the Medicare database) For 2018
For 2017
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Contact the individual or spouse to obtain the correct response, correct any other exceptions, and submit to processing. |
Question 7 – Providing one-half support to relatives living in beneficiary’s household
The question asks the beneficiary “How many relatives live with you and depend on you or your spouse for at least one-half of their financial support?”
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If… |
Then… |
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The beneficiary indicates “no change”; and The box is checked. |
MAPS ignores any other information placed in the blocks on Question 7. |
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The “no change” box is not checked; and There are no entries for a household number. |
MAPS determines the information on our records is correct. There should be no exception for this situation. |
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Any entry in number of household and the total value of all countable resources (in Question 5 or on the Medicare database) For 2018
For 2017
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MAPS does not generate an exception. MAPS processes the case as a termination. |
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Question 6 is checked “NO” for the individual and for the spouse (if a couple); There is an entry in number of household; and The total value of all countable resources (in Question 5 or on the Medicare database) For 2018
For 2017
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MAPS does not generate an exception. MAPS processes the case as a termination. |
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More than one block is checked for total number in the household or more than 9 is indicated; and The total value of all countable resources (in Question 5 or on the Medicare database) For 2018
For 2017
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Contact the beneficiary for the correct answer, check the proper number, correct any other exceptions, and submit it to Subsidy Determination. |
Question 8 – Unearned income
The question asks the beneficiary (ies) to provide information about any unearned income.
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If… |
Then… |
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The beneficiary indicates “no change” to the annual unearned income on the Resources and Income Summary; or The beneficiary checks the “no change” box. |
MAPS ignores any other information placed in the blocks on Question 9. MAPS does not generate an exception. |
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MAPS determines the information on our records is correct. There should be no exception for this question. |
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Total value of resources (in Question 5 or on the Medicare database) For 2018
For 2017
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MAPS does not generate an exception. MAPS processes the case as a termination. |
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Question 6 is checked “NO” for the individual and for the spouse (if a couple); and The total value of all countable resources (in Question 5 or on the Medicare database) For 2018 For an individual, is greater than $12,600 but less than $14,100; or
For 2017
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MAPS does not generate an exception. MAPS processes the case as a termination. |
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Enter 99999, correct all other exceptions, and submit it to Subsidy Determination. |
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WBDOC contacts the beneficiary to determine the correct answer, show the correct answer for Question 9, correct all other exceptions, and submit it to Subsidy Determination. |
Question 9 – Earned income
The question asks the beneficiary to provide information about annual earned income.
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If… |
Then… |
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The beneficiary indicates “no change” to the annual earned income on the Resources and Income Summary; and The “no change” box is checked. |
MAPS ignores any other information placed in the blocks on Question 10. MAPS does not generate an exception. |
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MAPS determines the information on SSA records is correct. There should be no exception for this question. |
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The total value of resources (in Question 5 or on the Medicare database) For 2018
For 2017
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MAPS does not generate an exception. MAPS processes the case as a termination. |
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Question 6 is checked “NO” for the individual and for the spouse (if a couple); and The total value of all countable resources (in Question 5 or on the Medicare database) For 2018
For 2017
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MAPS does not generate an exception.. MAPS processes the case as a termination. |
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Enter 999999, correct all other exceptions, and submit it to Subsidy Determination. |
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Contact the beneficiary to determine the correct answer, show the correct answer, correct any other exceptions and submit it to Subsidy Determination. |
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Amount shown in worksheet data is posted to new amount to clear any exceptions. |
Question 10– Impairment-Related Work Expenses/Blind Work Expenses (IRWEs/BWEs)
The question asks the beneficiary to provide information about any IRWEs or BWEs (also known as disability or blind work expenses).
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If… |
Then… |
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There are no boxes checked for this question. |
MAPS determines the information on our records is correct. There should be no exception for this situation. |
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The total value of resources (in Question 5 or on the Medicare database) For 2018
For 2017 For an individual, is over $13,820; or
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MAPS does not generate an exception. MAPS processes the case as a termination. |
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Question 6 is checked “No” for the individual and for the spouse (if a couple); and The total value of all countable resources (in Question 5 or on the Medicare database) For 2018
For 2017
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MAPS does not generate an exception. MAPS processes the case as a termination. |
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Answer is “Yes” and IRWEs or BWEs do not apply to this beneficiary, as the beneficiary has no earnings or is age 65 or older. |
MAPS ignores the answer and does not generate an exception. |
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Answer is “Yes” and ”No”; and There are IRWEs or BWEs on our records. |
MAPS determines the answer to be “yes” and does not generate an exception. |
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Answer is “Yes” and ”No”; and There are no IRWEs or BWEs on our records, there are earnings on our records or listed in Question 10, and the person may be eligible for IRWEs or BWEs. |
MAPS generates an exception to WBDOC to contact the beneficiary and determine the correct answer. Annotate the correct answer, correct any other exceptions, and then submit it to Subsidy Determination. |
Question 11 – Stopping work
The question asks the beneficiary to provide information about the plans to stop work.
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If… |
Then… |
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No date is present, Medicare database indicates earned income, or earned income is entered in Question 10. |
MAPS does not generate an exception. Submitting no answer is acceptable. |
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Date is present; No wages are on the Medicare database; and No wages are entered in Question 10. |
MAPS will generate an exception to WBDOC. Determine the correct information (wages or no wages), correct any other exceptions, and submit it to Subsidy Determination. |
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Date entered is before the current date. |
MAPS will generate an exception to WBDOC, as the question must be answered with a valid date. The date must be in the future. |
Signature and Change of address page
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If… |
Then… |
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The beneficiary checks the box indicating a change of address in the last three months. |
MAPS will generate an exception to WBDOC to check the Title II records and make corrective input, as necessary. |
C. WBDOC Procedures for contacting the beneficiary
1. Successful phone contacts
When you obtain the information by phone contact, take the following actions:
Input a Report of Contact on the DWRC screen, in the Report of Contact History section.
Indicate who provided the response to the question(s) and any other relevant information used to resolve the exception issue.
Complete the Report of Contact screen and click “OK” to return to the Exception (EXCP) screen and answer any pending exceptions.
Click the “Save” button and then click “Resolved” to submit the case to Subsidy Determination.
Prepare a Request for Information (RFI) if the beneficiary indicates he or she is no longer interested in receiving assistance, or if he or she is uncomfortable in providing the information over the phone. For instructions on completing an RFI see instructions in HI 03050.040C.3.
2. Unsuccessful phone contacts
When you are unable to reach the beneficiary by phone, take the following actions:
Complete a Report of Contact, after each unsuccessful phone contact. The Report of Contact screen should reflect the time of your unsuccessful phone attempt.
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Click “OK” to return to the DWMP screen.
NOTE: This application remains in pending status until it is submitted to Subsidy Determination.
Leave your phone number and extension and ask that they return your call, if you reach an answering machine. Also, state that you will be sending an RFI notice requesting the information needed to process their application. Do not leave the national 800 number.
Select the name from your pending list or enter the SSN on the MAPS Homepage to display the Medicare Query Display (QDIS) screen for that application, if the beneficiary calls back,
The status reflects “In Exception Process”.
Click on the Development Worksheet tab, and under the Issue Summary section, click on “Exception”. Questions that are in the exception status will be displayed.
Prepare a Report of Contact, click the “Save” button and then click “Resolved” to submit the case to Subsidy Determination. Once the beneficiary answers the questions.
3. Mailing an RFI notice
When it is necessary to mail an RFI to an applicant, take the following actions:
Click the “Generate Notice” button on the EXCP screen to print an RFI notice and mail it to the applicant. The RFI will ask each question on the SSA-1026 for which you need a response.
Use one envelope, if MAPS generates two notices due to a couple’s case with the same address.
Prepare a Report of Contact and establish a 15-day diary period, plus 5 days mail time for return of the notice.
Complete a Report of Contact screen documenting the action you will take and select “FTC-Determination” as the contact subject, if you are unsuccessful with your phone attempt and the 20-day RFI tickle date matures,.
Click on “Failure to Cooperate in the Issue Resolution” section on the EXCP screen and then submit to Subsidy Determination. The system will send out a Notice of Termination.
Do not click on “Failure to Cooperate” if the beneficiary responds to any of the questions on the RFI notice. The beneficiary’s response shows he or she is cooperating. Attempt to call the beneficiary in an effort to obtain the necessary information.
Process the application as “Failure to Cooperate” if you are unsuccessful.
D. WBDOC instructions for transferring MAPS redetermination exceptions to the FO
1. Exceptions routed to the servicing FO
Exceptions that are normally routed to the servicing FO are assigned to WBDOC office code L00. Additionally, some applications generate subsequent exceptions with the error message “There has been an error in the system after NUMI resolution. You may not continue to process this application” when cases are submitted to subsidy determination (SD). Submit cases that display this message to SD a second time. Take action on the subsequent exception.
Excluding item b. in HI 003050.000D.2. in this section, if the EXCP screen in MAPS displays one of the exceptions list, technicians must manually transfer the case to the servicing or designated FO.
2. Exceptions as displayed in MAPS
The following list are the exceptions the MAPS displays:
Manual Action Pending.
Previously Deemed – Review for Possible SSA-1020 .
Subsequent SSA-1026 Received – Possible Other Event.
SSA-1026 Received – Check for Possible Appeal.
SSA-1026 Received – Prior Action Pending.
SSA-1026 Received – Change in Household Composition.
Marital Status Does Not Correspond to Household Composition.
COSSN Does not Match Spouse on Record.
SSA-1026 Received- Develop for New SSA-1020 or Appeal for Good Cause.
Previous State Determination – Review for Possible SSA-1020.
Not in Proper Award Status.
SSA-1026 Filed With No Worksheet – Reprocess Using SSA-1026-SCE.
System Limitation – Cannot Complete Action.
WBDOC Exception Box – Application Cannot Be Edited.
No Redet or SCE Pending for Applicant – Please Review and Verify if This Is a Duplicate Form or a Subsidy Change Event Form.
System Limitation – Cannot Complete Action.
System Limitation (Code SDT03413) – Cannot Complete Action.
3. Instructions for the MAPS exception screen (EXCP)
From the EXCP screen in MAPS, take the following steps:
Complete a Report of Contact (DWRC screen) outlining why you are transferring the case to the designated office code. (For MAPS Report of Contact screen instructions see MS INTRANETMAPS 006.003.) . If the EXCP screen displays exception “Previously Deemed – Review for Possible SSA-1020”, follow the special processing guidelines in HI 03050.040D.4. in this section.
Transfer the exception to the servicing FO displayed on the STRF screen. If L00 is displayed as the servicing FO, obtain the correct FO from the payment line on the MBR.
Navigate back to the MAPS homepage and transfer the case.
4. Procedure for special processing guidelines for “previously deemed review for possible SSA-1020”
If you receive the exception, “Previously deemed – review for possible SSA-1020” take the following steps to verify and cancel this redetermination application-file SSA-1020:
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Review the Applicant(s) Data in MAPS and verify whether the person(s) is “Deemed Eligible” in the next calendar year. For redeterminations received in January through August, please verify whether the person(s) is “Deemed Eligible” for the current calendar year.
If Yes – go to step b.
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If No – go to step c.
NOTE: For couple’s applications – if one is deemed eligible for Extra Help and the spouse is not deemed, transfer the case to the servicing FO. Complete a Report of Contact (DWRC screen) outlining the reason for the transfer. For additional details about the Report of Contact screen, see MS INTRANETMAPS 006.003.
Cancel the redetermination application that is in “Exception Status” and send the “Medicare Subsidy Deemed Eligible” notice. Use the “Application Received” date displayed in the “Application Date” in the body of the notice. Complete a Report of Contact outlining the reason for cancelling the redetermination.
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Transfer the case to the servicing FO if MAPS does not show that the beneficiary has been deemed eligible for Extra Help. Complete a Report of Contact screen (DWRC) outlining the reason for the transfer. (For additional details about the Report of Contact screen, see MS INTRANETMAPS 006.003.)
The “Medicare Subsidy Deemed Eligible” notice is available from the WBDOC homepage.
E. Procedure when the system selects a beneficiary for Part D Extra Help redetermination and he or she is subsequently deemed eligible
When the system selects a beneficiary for a Part D Extra Help redetermination and the beneficiary becomes deemed for the current year before the SSA-1026-OCR-SM-REDE form is returned for processing and the beneficiary later returns the form, the MAPS generates the following exception message :
“Check Deemed Status for Previous Status for Next Calendar Year: This Applicant was Previously Deemed. If Deemed Already for Next Calendar Year, Cancel Redetermination. If Not Deemed Already for Next Calendar Year, Cancel Redetermination and Obtain an SSA-1020”.
The SSA-1026 application will go to exception status to WBDOC for review. Prior to the FOs receiving these exceptions, they should be routed to WBDOC for verification of current deemed status for Extra Help and processed per instructions in this section in HI 03050.040C.
F. References
HI 03035.000 Verification Process and Pre-Decisional Issues
HI 03050.025 Subsidy-Changing Event (SCE) and Other Event
HI 03050.035 Extra Help Redetermination Forms
HI 03050.045 Manual Correction Process for the Extra Help Application
HI 03020.001 What Is Income
HI 03020.005 What Is Not Income
HI 03030.001 What Are Resources for Medicare Part D?
HI 03030.025 Resource Limits for Subsidy Eligibility