TN 9 (06-07)

Citations:

Section 1860D-14(a)(3)(B) of the Social Security Act, 20 CFR 418.3220, 418-3225

A. Policy - valid application

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).

NOTE: When deemed status is no longer met, individuals are notified toward the end of the year and may file an application as early as September 1^st for the next year’s subsidy (see HI 03010.005F).

1. Valid application

To be valid the:

1. Application must be on a prescribed form (as described );

2. Application must be filed:

   • with a Social Security Administration (SSA) employee at one of our offices; or

   • with a SSA employee who is authorized to receive it at a place other than one of our offices; or

   • electronically through SSA’s Internet website, or

   • with a State Medicaid Agency; and

3. Claimant must be alive on the first day of the month in which the application is filed.

NOTE: A SSA application filed with the State must be adjudicated by SSA, and a State application filed with SSA must be adjudicated by the State.

2. Prescribed subsidy application filed with SSA

A prescribed subsidy application filed with SSA includes the:

• SSA-1020-OCR, scannable paper version

• i1020, online version on SSA’s Internet website

• Intranet (via Medicare Application Processing System (MAPS) completed by SSA employees.

A State subsidy application form is also a valid application but only if it is filed with and processed by the Medicaid State agency and communicated to CMS. The Department of Health and Human Services’ (HHS) regulations encourage States to use the SSA application (i.e., the SSA-1020-OCR or the i1020). However, if a person insists on a State determination, the State must use its own process. For any applications processed by the State, the appeal will also be processed by the state. Therefore, individuals who contact SSA with questions regarding their State application and/or appeal should be referred to the State.

B. Policy - proper applicant

In accordance with the HHS’ regulations, a proper applicant to file a subsidy application is a claimant or his/her personal representative.

A personal representative is defined as:

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

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

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

NOTE: A personal representative can include a representative of a third party entity, e.g., the Office of Aging, etc.

The claimant or his/her 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.

C. Policy - scope of application

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).

D. Policy - life of application

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 he/she files the application or before we make a final decision, the claimant will be sent a notice about his/her 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 he/she 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 him or her in a plan at the end of his or her 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 he/she becomes 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 he/she 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 03001.001E 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 him/her a notice. The notice will include appeal rights and inform the individual that he/she is not eligible for the subsidy because he/she is not entitled to Medicare Part A and/or enrolled in Medicare Part B.

E. Policy - death before effectuation

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:

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

• 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.

• 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:

• 1/2006, or

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

F. Policy - subsequent applications

1. Definition

A subsequent application is an application that SSA receives after one was previously submitted and possibly processed for the same individual or couple. A subsequent application may be considered a Duplicate Application in certain situations but not all subsequent applications are duplicate applications. A true duplicate application situation will have separate applications and can be identified by two separate listings on the Query Sub Menu Screen (QSMS).

NOTE: You should always request a MAPS Query (MSOM INTRANETMEDQ 001.009) before taking an application for extra help or responding to an inquiry.

CAUTION: A claimant cannot reapply for the subsidy for the purpose of having his/her partial subsidy determination reevaluated based on a change in the Federal Poverty Level (FPL). In fact, in some cases the higher FPL may not be to the claimant's advantage since a higher Title II amount would also be used. Therefore, if a subsequent application is filed, the application will be processed as a duplicate and Important Information Notice 2 sent to the claimant per instructions in HI 03010.010F.5.a.

2. Processing subsequent applications - both applications received by SSA

a. Disposition of subsequent paper applications received in the field office (FO)

When the FO receives a subsequent paper application, forward the application to WBDOC where it will be processed through the scanning operation. The address varies depending on the application received.

• For SSA-1020 use:

  P.O. Box 1020 Wilkes-Barre, PA 18767-1020

• For SSA-1026 use:

  P.O. Box 1080 Wilkes-Barre, PA 18767-1080

• For SSA-1021 use:

  P.O. Box 1030 Wilkes-Barre, PA 18767-1030

• For Request for Information use:

  P.O. Box 1077 Wilkes-Barre, PA 18767-1077

NOTE: If the FO receives paper applications that are not subsequent (i.e., it is the first application or appeal), the FO should enter these applications into MAPS.

b. Processing subsequent applications

The action needed on a subsequent application will depend on the circumstances as outlined in the following chart.

Subsequent Application Chart

3. Processing subsequent applications - one application is processed by SSA the other is processed by a State medicaid agency

If both SSA and a State Medicaid agency process an application for the same person, CMS will determine which application is the official one based on the chart below. CMS will notify the beneficiary and each agency.

4. Processing cases when an incorrect SSN was previously used and the NH for that SSN now wants to file an application

These instructions refer to cases where an incorrect SSN was used on an application for a spouse and that application has been processed. The individual that the SSN belongs to contacts SSA and wishes to file an application. However the original incorrect application is still within the appeals period.

a. First application was denied

Load the new application using the correct SSN and protective filing date, and process as usual.

b. First application was allowed

If the error is discovered within 60 days of receipt of the favorable initial determination or fully favorable hearing decision, follow the instructions in HI 03050.005C.6. for correcting errors using the manual correction process.

5. Notices

a. Notices used for processing subsequent applications

The following notices will be used for processing subsequent applications. Important Information Notices 1 and 3 are available on DPS, but Important Information Notice 2 is generated by MAPS and is not available on DPS:

• Important Information Notice 1 advises the individual that we have received a subsequent application from a third party but we will not process it. The individual will be told to contact the 800# if he/she was attempting to appeal. See HI 03094.610 for an exhibit of this notice.

• Important Information Notice 2 advises the individual that the determination on the first application remains in effect for 12 months unless he/she reports a subsidy changing event. See HI 03094.615 for an exhibit of this notice.

• Important Information Notice 3 advises the individual that we have received a duplicate application which we will not process. See HI 03094.620 for an exhibit of this notice.

b. Required Action if the person calls as a result of the above notices

• If the person wants to file an appeal, complete the appeal screens in MAPS.

• If the person says he/she was trying to report a subsidy changing event (per HI 03050.005) or was reporting a non-subsidy changing event between August 1 and December 31 of any year, review the second application. If the change is on the form, refer to an adjudicator to make the change. Do not send another SSA-1020.

• If the person was trying to report an event which is not a subsidy changing event between January 1 and July 31 of any year, advise the person that we will contact him or her after August of the current year for a redetermination. Annotate the system to indicate a report was made per HI 03050.005. If the report affects other program benefits that the claimant receives, take the appropriate action.