HI 03090.001: Medicare Part D Notices - General

changes
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~~Effective Dates: 02/15/2018 - Present~~
Effective Dates: 03/07/2018 - Present
TN 4 (12-06)
HI 03090.001 Medicare Part D Notices - General
A. General
This subchapter provides an overview of Medicare Part D subsidy notices. See HI 03094.000 for exhibits of specific notices. See HI 03092.000 for the individual paragraphs used in creating Part D notices.
B. Policy
1. When we send a notice
We send a notice for initial determinations of subsidy eligibility. We also send a notice for post-entitlement redeterminations. These notices contain appeal rights. A pre-decisional notice is sent to applicants who appear ineligible for the subsidy. This notice does not contain appeal rights.
We send notices for some actions that cannot be appealed, including dismissing duplicate applications, requesting additional information or evidence to process an application and denial of good cause for late filing of an appeal.
2. When a notice is not required
No notice is sent when a duplicate application is cancelled while the initial application is still pending. A notice is not sent when a subsidy terminates due to death.
3. Who receives notices
Anyone who applies for a subsidy will be sent a notice. A notice will also be sent anytime a redetermination is completed, whether or not there has been a change in the subsidy.
Unlike Title II and Title XVI, subsidy notices are not sent to representative payees, legal guardians, parents of minor children, or authorized representatives.
4. Blind and visually impaired notices
We use the Special Notice Option (SNO) formats to send blind and visually impaired subsidy notices.
5. Headings on notice
A three-line heading is used for subsidy notices:
* The first line is “Social Security Administration.”
* The second line is “Extra Help with Medicare Prescription Drug Plan Costs.”
* The third line is the title of that notice; for example, “Notice of Award.”
We use the following third-line titles for initial and post-entitlement actions: Application Development, Pre-Decisional Notice, Notice of Award, Notice of Denial, Notice of Review, Notice of Change, Notice of Planned Action, Notice of Termination, and Important Information. There are some additional titles used on appeal notices.
6. Return address
The return address on automated subsidy determination notices will be the servicing processing center (PC). The PC jurisdiction is based on the Beneficiary Own Account Number (BOAN) and not based on the Social Security Number (SSN) under which the claimant is being paid Title II benefits.
7. Signatures
Subsidy award notices will show the signature of the Commissioner of Social Security in the signature block. The signature block on other subsidy determination notices will show “Social Security Administration.”
8. Mailing
This section explains the notice date on Medicare subsidy notices and mailing timeframes.
Manually prepared notices are dated the day you prepare them;
Automated notices are dated 5 days from the date the notice was generated by a transaction in Medicare Application Processing System (MAPS);
Allow 5 days mail time from the date on the notice (automated and manually prepared) to determine the 10-day period for subsidy continuation and the 60-day appeal period.
C. Description of systems used to produce Medicare subsidy notices
This subsection explains the various computer systems used to produce Medicare subsidy notices.
Medicare subsidy notices will be created using the following notice systems:
* MAPS is used to generate determination notices, request for information notices for exceptions, request for information or evidence notices for verifications and pre-decisional notices;
* Document Generation System (DGS) is used to create appeals notices;
* Document Processing System (DPS) is used to prepare some application development, dismissal, and manual award and/or denial notices;
* The 800 Number System will contain appointment and protective filing closeout notices.
Notices prepared in MAPS, DGS, and DPS will be stored in the Online Retrieval System (ORS).
D. Procedure - undeliverable subsidy notices and forms Income and Resource Summary (SSA-1026SCE), Medicare Prescription Drug Assistance Notice of Review (SSA-L1026) and Statement for Continuing Eligibility for Help With Medicare Prescription Drug Plan Costs (SSA-1026-OCR-SM-REDE)
1. Re-mail undeliverable mail – subsidy determination notices - PC action
Automated Medicare Notices can be identified by a large “M” on the envelope. When a notice is returned as undeliverable, create an Action Control Record for the re-mailing and use Type of Event Level (TOEL) code MEDACT UNDEL. Develop for a new address as follows:
a. Forwarding address available
Check the envelope for a forwarding address from the Post Office. If a forwarding address is found, update the MBR, re-date and re-mail the notice. Mark the outgoing envelope with a large, red “R” (for re-mail) on its lower left corner. Also, document the undeliverable mail action taken on a Report of Contact (RC) in MAPS.
For Pre-Decisional Notices, extend the pre-decisional period. To do this, enter your unit code on the Development Worksheet and click on the pre-decisional issue. Check the Decision Date field on the Pre-Decisional Period screen (DWPD). If this date has not expired, extend the Decision Date 30 days from the date shown. If the Decision date has expired, you cannot extend the date. Document on a DWRC screen in MAPS the reason for the extension or the fact that the decision date expired and cannot be extended. Also include on the DWRC the date the notice was re-mailed.
b. Query MAPS
Query MAPS to obtain a better address by doing the following process:
* If a forwarding address is not available, query MAPS to see if a scanned image of the application is available. On the MAPS home page, enter the SSN of the individual, click on Query and then click on “Scanned Image of Application” button. If this button is grayed out, the image is not available.
* If the image is available, review the signature page of the scanned image for an address.
* Also, query the Railroad Retirement Board (RRB) Address line on the “Applicant Data” section of the MAPS Query for a better address.
* If a different address is found, update the MBR (if available), re-date and re-mail the notice. Mark the outgoing envelope with a large, red “R” (for re-mail) on its lower left corner. Also, document the undeliverable mail action taken on a Report of Contact (RC) in MAPS. For Pre-decisional Notices extend the pre-decisional period as explained in section HI 03090.001D.1.a.
* If a more current address is not found, follow the instructions in HI 03090.001D.1.c. for checking the MBR.
c. Query the MBR
If a more current address is found, re-date and re-mail the notice. Mark the outgoing envelope with a large, red “R” (for re-mail) on its lower left corner. Also, document the undeliverable mail action taken on a RC in MAPS. For Pre-Decisional Notices extend the pre-decisional period as explained in section HI 03090.001D.1.a.
If a more current address is not found, check for a SID line on the MBR. Query the SSR when a SID line is present for a more current address. If a more current address is found, update the MBR and re-mail the notice. Mark the outgoing envelope with a large, red “R” (for re-mail) on its lower left corner. Also, document the undeliverable mail action taken on a RC in MAPS. For Pre-Decisional Notices extend the pre-decisional period as explained in section HI 03090.001D.1.a.
If further SSI development is needed, refer to the servicing FO.
d. Better address not found on MBR/SSR/MAPS
If a better address is not found, re-date and re-mail the notice to the same address. Place the notice in a new envelope, mark the new envelope with a large, red “R” (for re-mail) in its lower left corner and document the undeliverable mail action taken on a RC in MAPS. For Pre-Decisional notices extend the pre-decisional period as explained in section HI 03090.001D.1.a.
If the notice is returned as undeliverable a second time and the person is receiving Title II Benefits, determine whether the beneficiary receives his/her benefits by direct deposit or check, and follow GN 02605.055B.3. If the person is not receiving any benefits, document on a RC in MAPS that the notice was returned undeliverable a second time and take no further action.
2. Re-mail undeliverable mail – request for information notices WBDOC/DERO/WSU/FO action
Wilkes-Barre Direct Operations Center (WBDOC), Division of Earnings Record Operations (DERO), WSUs and FOs send the Request for Information Notice to request information that is needed to resolve an exception. This notice is locally generated by MAPS when the user clicks on the “Create Notice” button on the Exception screen. WSUs and FOs also send the Request for Information or Evidence Notice to request additional information or evidence that is needed to resolve verification issues. This notice is locally generated by MAPS when the user clicks on the “Generate Notice” button on the Verification screen. If these notices are returned as undeliverable, process as follows:
a. Forwarding address available
Check the envelope for a forwarding address from the Post Office. If a forwarding address is found, update the MBR, reset the tickle date for 20 days on the exception screen for the Request for Information Notice or the verification screen for the Request for Information or Evidence Notice, re-date and re-mail the notice. Mark the outgoing envelope with a large, red “R” (for re-mail) on its lower left corner. Also, document the undeliverable mail action taken on a DWRC in MAPS.
b. Query MAPS
If a forwarding address is not available query MAPS to obtain a current address by doing the following process:
* Query MAPS to see if a scanned image of the application is available. On the MAPS home page, enter the SSN of the individual, click on Query and then click on “Scanned Image of Application” button. If this button is grayed out, the image is not available.
* If the image is available, review the signature page of the scanned image for an address.
* Also, query the Railroad Retirement Board (RRB) Address line on the “Applicant Data” section of the MAPS Query for a better address.
* If a different address is found, update the MBR (if available), re-set the tickle date for 20 days on the exception screen for the Request for Information Notice or the verification screen for the Request for Information or Evidence Notice re-date and re-mail the notice. Mark the outgoing envelope with a large, red “R” (for re-mail) on its lower left corner. Also, document the undeliverable mail action taken on a DWRC in MAPS.
* If a current address is not found, follow the instructions in HI 03090.001D.2.c. for checking the MBR.
c. Query the MBR
If a more current address is found, re-set the tickle date for 20 days on the exception screen for the Request for Information Notice or the verification screen for the Request for Information or Evidence Notice re-date and re-mail the notice. Mark the outgoing envelope with a large, red “R” (for re-mail) on its lower left corner. Also, document the undeliverable mail action taken on a DWRC in MAPS.
d. Better address not found on MBR/SSR/MAPS
If better address is not found, re-date, re-mail the notice to the same address and re-set the tickle date for 20 days on the exception screen for the Request for Information Notice or the verification screen for the Request for Information or Evidence Notice. Mark the outgoing envelope with a large, red “R” (for re-mail) on its lower left corner. Also, document the undeliverable mail action taken on a DWRC in MAPS.
e. Second round undeliverables
If the notice comes back as undeliverable the second time, process as “Failure to Cooperate” when the tickle matures.
3. Re-mail undeliverable mail - Forms SSA-1026SCE, SSA-L1026 and SSA-1026-OCR-SM-REDE – WBDOC action
MAPS automatically sends out the Redetermination Notice (cover letter) and the redetermination form SSA-1026SCE when a subsidy changing event is reported (HI 03050.005). If the beneficiary does not return the SSA-1026SCE form in 90 days, the subsidy will be terminated. Also, MAPS sends out two notices for redetermination of eligibility, which are the SSA-L1026 and SSA-1026-OCR-SM-REDE (See HI 03050.011). If form SSA-1026SCE, SSA-L1026 and SSA-1026-OCR-SM-REDE are returned as undeliverable, process as follows:
a. Forwarding address available
Check the envelope for a forwarding address from the Post Office. If a forwarding address is found, update the MBR, extend the tickle date for an extra 30 days on the Subsidy Continuation screen (DWSC), for the SSA-1026 SCE, SSA-1026-OCR-SM-REDE (there is no tickle date for the SSA-L1026, re-date the cover letter and re-mail it with the SSA-1026SCE, SSA-1026-OCR-SM-REDE or the SSA-L1026. Mark the outgoing envelope with a large, red “R” (for re-mail) on its lower left corner. Also, document the undeliverable mail action taken on a DWRC in MAPS using “Other” as the contact method and contact subject.
b. Query MAPS
If a forwarding address is not available query MAPS to obtain a current address by doing the following process:
* Query MAPS to see if a scanned image of the application is available. On the MAPS home page, enter the SSN of the individual, click on Query and then click on “Scanned Image of Application” button. If this button is grayed out, the image is not available.
* If the image is available, review the signature page of the scanned image for an address.
* Also, query the RRB Address line on the “Applicant Data” section of the MAPS Query for a better address.
* If a different address is found, update the MBR (if available), extend the tickle date for an extra 30 days on the Subsidy Continuation Screen (DWSC) for the SSA-1026SCE, SSA-1026-OCR-SM-REDE (there is no tickle date for the SSA-L1026, re-date the cover letter and re-mail it with the SSA-1026SCE, SSA-1026-OCR-SM-REDE or the SSA-L1026. Mark the outgoing envelope with a large, red “R” (for re-mail) on its lower left corner. Also, document the undeliverable mail action taken on a DWRC in MAPS.
* If a current address is not found, follow the instructions in HI 03090.001D.3.c. for checking the MBR.
c. Query the MBR
Review the EDA field on the PAYMENT line of the MBR. If the date on the EDA reflects a more current address is found, extend the tickle date for an extra 30 days on the DWSC for the SSA-1026SCE, SSA-1026-OCR-SM-REDE (there is no tickle date for the SSA-L1026), re-date the cover letter and re-mail it with the SSA-1026SCE, SSA-1026-OCR-SM-REDE or the SSA-L1026. Mark the outgoing envelope with a large, red “R” (for re-mail) on its lower left corner. Also, document the undeliverable mail action taken on a DWRC in MAPS.
If a more current address is not found, check for a SID line on the MBR. Query the SSR when a SID line is present for a more current address. Check the ACD field on the ADDR line of the SSR. If the ACD date indicates a more current address is found, update the MBR, extend the tickle date for an extra 30 days on the DWSC for the SSA-1026SCE, SSA-1026-OCR-SM-REDE (there is no tickle date for the SSA-L1026), re-date the cover letter and re-mail it with the SSA-1026SCE, SSA-1026-OCR-SM-REDE or the SSA-L1026. Mark the outgoing envelope with a large, red “R” (for re-mail) on its lower left corner. Also, document the undeliverable mail action taken on a DWRC in MAPS.
d. Better address not found on MBR/SSR/MAPS
If better address is not found, re-date the cover letter and re-mail it with the SSA-1026SCE, SSA-1026-OCR-SM-REDE or the SSA-L1026 to the same address. Also, extend the tickle date for an extra 30 days on the DWSC for the SSA-1026SCE, SSA-1026-OCR-SM-REDE (there is no tickle date for the SSA-L1026). Mark the outgoing envelope with a large, red “R” (for re-mail) on its lower left corner. Also, document the undeliverable mail action taken on a RC in MAPS.
e. Second round undeliverables
If the notice comes back as undeliverable the second time, no further action is needed. Subsidy will be automatically terminated when the tickle matures for the SSA-1026SCE, SSA-1026-OCR-SM-REDE.
E. Procedure - undeliverables marked deceased (WBDOC/PSC action)
1. WBDOC
If WBDOC receives an undeliverable SSA-1020, SSA-L1026, SSA-1026SCE, SSA-1026-OCR-SM-REDE marked “deceased”, query the MBR to determine if the record has been updated with the death input:
* If the MBR is in LAF T1 status, destroy the SSA-1020, SSA-L1026, SSA-1026SCE, SSA-1026-OCR-SM-REDE.
* If the MBR is not in LAF T1 status, route the undeliverable SSA-1020, SSA-L1026, SSA-1026SCE, SSA-1026-OCR-SM-REDE marked “deceased” to the servicing PC for verification action.
2. PSC
If you receive undeliverable SSA-1020, SSA-L1026, SSA-1026SCE, SSA-1026-OCR-SM-REDE marked “deceased” from the WBDOC, because the MBR is not in LAF T1 verify the death. (See GN 02602.050)
F. References
Follow these specific references for developing mail in the following special situations:
* GN 02605.055B.3., Title II Undeliverable Mail- COA,.
* GN 02602.050, Processing Reports of Death,
* GN 02605.060, Title XVI Undeliverable Notices.
G. Extra help with Medicare prescription drug plan costs applications requiring manual award, denial or termination notices
Assigned office should follow these instructions for processing the case and releasing a notice, if required. Offices should access the NY Medicare Follow-up website at the following URL to obtain the manual notice cases assigned to them: http://nynet.ny.ssa.gov/MedicareFollowup . These actions will be captured under “Action Type: Manual Notice Needed” on the website. After processing the case using the following instructions, access the Intranet Application Processing screen on the website to post the appropriate results of your actions as described below:
* CORRECT DETERMINATION-DENIAL NOTICE SENT: [Notice Date]
* CORRECT DETERMINATION-AWARD NOTICE SENT: [Notice Date]
* CORRECT DETERMINATION-TERMINATION NOTICE SENT: [Notice Date]
* INCORRECT AWARD NO MEDICARE-DENIAL NOTICE SENT: [Notice Date]
* NO NOTICE SENT-INCORRECT SSN AWARD
* NO NOTICE SENT-SPOUSE-DID NOT FILE
* NO NOTICE SENT-DEEMED
* NO NOTICE SENT-APPEAL
* NO NOTICE SENT-DECEASED
* NO NOTICE SENT-INCORRECT DENIAL
* NO NOTICE SENT-NEW APPLICATION ESTABLISHED
1. Notice preparation
a. Award notice
If you are preparing an award notice, access the “Medicare Subsidy Award Notice” which is under the “General” menu category in DPS. Use the income, resource, household and determination data in MAPS to produce a detailed notice as shown in HI 03094.201.
DPS has no resource or income computation sheets so it will not be necessary to provide these on the manual notices.
b. Denial notice
If you are preparing a denial notice, access the “Medicare Subsidy Denial Notice” which is also under the “General” menu category in DPS. Again use the income, resource household and determination data in MAPS to produce a notice as shown in HI 03094.210.
EXAMPLE: If the applicant answers “yes” to question 3 on the application indicating that his/her is over the resource limit but does not provide detailed information about their resources and income, the denial notice would use MPD111 as the reason for denial and MPD095 (Did not provide enough information.) under the listing of resources.
c. Termination notice
If the Part D subsidy terminated (most of the time this occurs as a result of a redetermination processing) and you are preparing a termination notice, access the “Medicare Subsidy - Notice of Termination” which is under the “General” menu category in DPS. Use the income, resource, household and determination data in MAPS to produce a detailed notice as shown in HI 03094.310.
Information on the contents of the specific award, denial and termination notice paragraphs is provided in HI 03092.005.
The notice should:
* Contain the Manager’s signature of the office sending the notice;
* The Beneficiary’s own SSN;
* Be placed on the Online Notice Retrieval System unless a systems limitation prevents that; and
* Contain the current address available on our records.
2. MAPS query
Keep in mind the MAPS query may contain an incorrect address from the MBR if the individual filed under an incorrect SSN. You may need to view the scanned image of the application to obtain the current address. Review MAPS to screen out cases requiring no notice:
* Review Question 2 on the subsidy application to determine if the spouse filed an application. If the spouse did not file an application, post the following result to the New York Medicare Follow-up website: NO NOTICE SENT-SPOUSE-DID NOT FILE. Take no further action.
* Review deemed status to determine if the individual needing the notice is deemed eligible. If deemed eligible, post the following result to the New York Medicare Follow-up website: NO NOTICE SENT-DEEMED. Take no further action. If the individual needing the notice is not deemed eligible, go to c.
* If case has a pending or resolved appeal (regardless of whether a single or couple’s application is involved), post the following result to the New York Medicare Follow-up website: NO NOTICE SENT-APPEAL. Take no further action.
* If individual is deceased, post the following result to the New York Medicare Follow-up website: NO NOTICE SENT-DECEASED. Take no further action.
3. Case does not meet criteria in HI 03090.001G.2.
If the case does not meet criteria in HI 03090.001G.2., review MAPS, MBR, SSID and Numident to determine if MAPS determination is correct.
MAPS users in the FO, WSU or SAU may determine that an error on a MAPS application impacts the subsidy determination and cannot be corrected using normal procedures. The error(s) could be caused by scanning, keying or incorrect information from the applicant.
As of August 2006, the manual correction process permits users in the FO, WSU and SAU to correct problems. This process can be used to correct an applicant’s SSN. A case must be processed to an award or denial in order to utilize the manual correction process. Identified errors can be corrected within 60 days of the initial determination or hearing decision. See HI 03050.005C.6. for further instruction.
a. MAPS determination is an incorrect award
Complete the following process if the MAPS determination is an incorrect award:
* If the MAPS determination is an incorrect award as the individual is not eligible for Medicare or within 3 months of Medicare eligibility, release the denial notice and document the reason for the denial and the date of the notice on a DWRC in MAPS. Also, post the following result to the New York Medicare Follow-up website: INCORRECT AWARD NO MEDICARE-DENIAL NOTICE SENT: [Notice Date].
* If the MAPS determination is an incorrect award as the SSN is incorrect, post the following result to the New York Medicare Follow-up website: NO NOTICE SENT-INCORRECT SSN AWARD-
b. Determination is a correct denial
If the determination is a correct denial:
* If the SSN is correct on MAPS, issue the denial notice based on the MAPS determination. Post the following result to the New York Medicare Follow-up website: CORRECT DETERMINATION-DENIAL NOTICE SENT: [Notice Date].
* If the SSN is incorrect on MAPS and your review identified the correct SSN (e.g., on application image), use the manual correction process to correct the SSN. Using the manual correction process will result in a new application being established under the correct SSN in MAPS. On the MAPS development worksheet main (DWMP), review the determination effective date, which appears below the development issues. If the date is not the proper date, click on the edit button. You will be taken to the edit determination dates-initial application (DEDI) screen. On the DEDI screen you can edit the protective filing date, which will affect the determination effective date. The system should release a notice with the proper award or denial determination but may not have the proper application date. Post the following result to the New York Medicare Follow-up website: NO NOTICE SENT-NEW APPLICATION ESTABLISHED.
* If the SSN is incorrect on MAPS and your review did not identify the correct SSN, follow HI 03010.040 procedures for requesting evidence to obtain the SSN from the individual.
* If you obtain the correct SSN from the individual, follow instructions in HI 03090.001G.3.b. to use the manual correction process, and to address any protective filing involved. The system should release a notice with the proper award or denial determination but may not have the proper application date. Post the following result to the New York Medicare Follow-up: NO NOTICE SENT-NEW APPLICATION ESTABLISHED.
* If the individual fails to provide the correct SSN, issue a denial notice based on failure to cooperate. Document the reason for denial on a DWRC on MAPS. Do not include the incorrect SSN on the denial notice. Post the following result to the New York Medicare Follow-up website: CORRECT DETERMINATION-DENIAL NOTICE SENT: [Notice Date].
c. Determination is an incorrect denial
If the determination is an incorrect denial (e.g., income or resource amount used was incorrect):
* If you are able to determine the correct information from reviewing the records follow instructions in HI 03090.001G.3.b. to use the manual correction process, and to address any protective filing involved. Document on a DWRC on MAPS the reason for using the manual correction process. The system should release a notice with the proper award or denial determination but may not have the proper application date. Post the following result to the New York Medicare Follow-up website: NO NOTICE SENT-NEW APPLICATION ESTABLISHED.
* If you are unable to determine the correct information from reviewing the records, post the following result to the New York Medicare Follow-up website: NO NOTICE SENT-INCORRECT DENIAL. Take no further action.
d. MAPS determination is a correct award
If the SSN is correct on MAPS, issue the award notice based on the MAPS determination. Post the following result to the New York Medicare Follow-up website: CORRECT DETERMINATION-AWARD NOTICE SENT: [Notice Date].
4. BOAN must be posted to MBR
If the BOAN must be posted to MBR to enable System to identify Medicare eligibility, follow these instructions.
a. No BOAN on MBR, therefore no data for spouse on MAPS
If the MAPS Query Display did not pick up any of the following:
* Title II Claim number in the Applicant Data,
* Medicare Data on Applicant/Spouse Enrollment History,
* SSA benefit amount under Current Agency Data benefit.
Determine the claim number under which benefits are paid (if not shown on the spouse’s record). Usually the problem exists for older MBRs that involve widow/widowers.
~~b. Medicare number~~
b. Medicare Number
Ask the person for his/her Medicare Number on their Medicare card. (Follow HI 03010.040 procedures for requesting evidence to obtain the SSN from the individual.)
If the individual provides the Medicare Number:
* Check the MBR using the SSN under which Medicare benefits are paid.
* Look for the BENREF line right after the BENEFIT line on the MBR for the individual.
* If there is no BENREF listed on the MBR or the SSN listed is incorrect, it must be corrected to show the beneficiary’s own SSN.
* MAPS cannot produce the correct data for a determination unless the SSN of the applicant is on the record where they receive benefits.
c. Resolve the problem
To correct the BOAN on the MBR, do the following:
* On the SSA Main Menu, select #2, Title II/PE
* On the Title II PE Menu select #2, MONET
* On the NSEL screen, enter the claim number under which benefits are paid
* On the IMAM screen, select #10, Beneficiary Reference Data for the correct beneficiary
* On the BREF enter the beneficiary’s own account number (BOAN)
* Follow instructions in HI 03090.001G.3.b. to use the manual correct process, and to address any protective filing involved. Document on a DWRC in MAPS the reason for using the manual correction process. The system should release a notice with the proper award or denial determination.

POMS Reference

HI 03090.001: Medicare Part D Notices - General