TN 16 (11-12)

A. Description of Extra Help

Extra Help assists Medicare beneficiaries with limited income and resources with their Medicare prescription drug plan costs (i.e., premiums, deductibles, and copayments). We designed the application questions to help determine an individual’s eligibility and the correct amount of Extra Help subsidy. For eligibility criteria see HI 03001.020.

B. Procedure for the scannable form

1. Completing and forwarding the SSA-1020-OCR

Imbedded on the scannable form are instructions for providing answers to the questions. You should assist the applicant, as needed in completing the form.

If the field office (FO) receives an SSA-1020-OCR, Application for Extra Help with Medicare Prescription Drug Plan Costs, in-person, by mail, or at an outreach event, the FO should enter the application data into the Medicare Application Processing System (MAPS).

EXCEPTION: If the claimant answers question 3 “yes” (claimant alleges resources exceed the limit) and any subsequent questions are unanswered, FOs should mail those applications to the Wilkes-Barre Direct Operations Center (WBDOC) to process. The SSA-1020-OCR includes the WBDOC mailing address. For more information on question 3, see HI 03010.038C.3. in this section.

2. Entering the filing date in the Official Use Only Block:

Follow these instructions when completing the Official Use Only Block:

• If you forward the SSA-1020-OCR to the WBDOC, handwrite the date (MM/DD/YYYY) you receive the application within the white space of the block.

  EXCEPTION: If local procedures require the use of a date stamp, stamp the date on the cover notice of the form on the right side below the bolded blue line.

• Be careful not to make any entries or marks in the State code or WBDOC Exception blocks, or on the barcode. Doing so will prevent the form from scanning.

• Before forwarding the form, enter the letter “H” after the word “Only” in the “For Official Use Only” block, so the WBDOC can determine the proper filing date (as explained in HI 03010.015).

• State employees will handwrite the date they receive the SSA-1020-OCR in the State Medicaid agency.

Leave the WBDOC Exception block blank.

For filing date policy, see HI 03010.015 and for protective filing policy, refer to HI 03010.020.

3. Applicant submits photocopy of SSA-1020-OCR

A photocopied SSA-1020-OCR will not scan. If the applicant submits a photocopy, rather than an original SSA-1020-OCR, enter the information into MAPS or complete a new SSA-1020-OCR if the system is down. Do not forward the photocopy to the WBDOC.

C. Procedure for application questions

1. Claimant's name and Social Security Number (SSN) and date of birth (DOB)

We require the claimant's name, SSN, and DOB on the SSA-1020-OCR.

2. Marital information

If the claimant is married and lives with the spouse, we require the spouse's name, SSN, and DOB. (Accept the individual's allegation of marital status. The Title XVI holding out policy does not apply to Medicare Part D.)

This information serves two purposes.

• A couple filing for the subsidy at the same time only needs to complete one application. Therefore, we ask if the spouse has Medicare and wishes to apply for the Extra Help.

• It facilitates data matching for the spouse.

NOTE: If the spouse does not have an SSN or does not know it, process the claim following the procedures in HI 03010.038F in this section. Also, when the FO receives a paper application and the applicant is not in the FO to provide marital information (e.g., single, married, widowed, or divorced), code the individual as single if the applicant did not list a spouse on the paper application. Code the individual as married if a spouse is listed on the application.

We collect this information on the Applicant Information application screen in MAPS (see MSOM INTRANETMAPS 005.002).

3. Total amount of resources

This question serves as a self-screener for the applicant. By indicating the resource limit, which includes the burial expense exclusion (more than $14,100 for a single individual and $28,150 for a couple in 2018); the applicant can decide whether to pursue the application. The applicant needs to complete the application to receive a formal decision on the claim. For more information on resources, refer to HI 03030.001 through HI 03030.025. (When claimants file in person or by telephone, discuss the resource limit during the pre-application interview.)

We collect the response to this question on the Savings and Accounts application screen in MAPS (see MSOM INTRANETMAPS 005.004).

NOTE: When the FO receives a paper application (in-person, by mail, or at an outreach event) with this question answered “yes” and any subsequent questions unanswered, forward the application to the WBDOC to process. Otherwise, process the application through MAPS.

4. Liquid resources

We need to know the amount of resources an individual has in order to determine eligibility for the subsidy.

• If the claimant is single, we count only that person's resources (including jointly-owned resources).

• If the individual is married and lives with his or her spouse, we count the resources of both spouses, regardless of whether one or both spouses are filing for the subsidy.

For the definition of liquid resources, see HI 03030.001 and for liquid resources verification policy, see HI 03035.020.

We collect the allegation of liquid resources on the Savings and Accounts application screen in MAPS (see MSOM INTRANETMAPS 005.004).

5. Funeral or burial funds

The claimant can have up to $1,500 (up to $3,000 for a couple) for funeral or burial expenses excluded from the subsidy resource limit. For a discussion of excluded burial funds, see HI 03030.020B.

We collect the burial funds allegation on the Insurance, Burial Information and Real Estate application screen in MAPS (see MSOM INTRANETMAPS 005.005).

6. Real estate

We need to know the value of real property, other than the home where the claimant(s) lives and the property on which it's located, because the value of such property counts toward the resource limit for the subsidy (see HI 03030.001). For verifying an allegation of other property, see HI 03035.030.

We collect the allegation about real estate on the Insurance, Burial Information and Real Estate application screen in MAPS (see MSOM INTRANETMAPS 005.005).

7. Household composition size

We consider relatives who live with the claimant(s) and for whom the claimant(s) provides at least one-half support to be part of the claimant's household. A relative is someone related by blood, adoption, or marriage; excluding the spouse if married and living together. We use the size of the household to determine the percentage of the Federal Poverty Level (FPL) applicable. For more information on subsidy eligibility see HI 03020.055.

We collect the number of relatives in the household for whom the claimant provides one-half support on the No. of Relatives & Help with Expense application screen in MAPS (see MSOM INTRANETMAPS 005.003).

8. Unearned income

For purposes of determining eligibility and whether the claimant should receive a full or partial subsidy, SSA considers all of the unearned income a claimant (and the claimant's spouse if the couple lives together) receives. For how we count unearned income, see HI 03020.040 and for verification policy, see HI 03035.005.

We collect the alleged unearned income on the Unearned Income application screen (see MSOM INTRANETMAPS 005.006).

9. Decrease in unearned income

Decreases in unearned income could affect the eligibility for, and amount of, a subsidy. Use this question to explain discrepancies between the information in Question 8 and the data received from other agencies. For income verification policy, see HI 03035.010.

We collect the alleged decrease in unearned income on the Unearned Income application screen in MAPS (see MSOM INTRANETMAPS 005.006).

10. Wages

For purposes of determining eligibility and whether the claimant should receive a full or partial subsidy, SSA considers all wages a claimant (and the claimant's spouse, if the couple lives together) receives. To determine how we count wages see HI 03020.025 and for verification policy, see HI 03035.005.

We collect the allegation of wages on the Earned Income application screen in MAPS (see MSOM INTRANETMAPS 005.007).

11. Self-employment

We consider net earnings from self-employment (NESE) the claimant(s) (or the claimant's spouse if the couple lives together) receives as income for the purposes of determining eligibility for, and the percentage of, the subsidy. For how we count this income and the effects of a net loss from self-employment income (SEI), see HI 03020.025. For verification policy, see HI 03035.005.

We collect the allegation of NESE on the Earned Income application screen in MAPS (see MSOM INTRANETMAPS 005.007).

12. Decrease in wages or Self-Employment Income (SEI)

The amount of wages or SEI may have decreased since it was last recorded by the Agency’s data source, the Office of Child Support Enforcement (OCSE). The claimant should report a decrease in wages or SEI because it could affect eligibility for, or amount of, the subsidy. A reported decrease in earnings may enable us to resolve a discrepancy between OCSE data and the amount of alleged wages or NESE without having to contact the claimant. If there is a net-loss in SEI, we deduct the loss from any wages the person may have. For income verification policy, see HI 03035.010.

We collect decreased wage information on the Earned Income application screen in MAPS (see MSOM INTRANETMAPS 005.007).

13. Work stopped or will stop

This information will allow us to project wages for the coming year.

Stopping work could affect eligibility for, and the percentage of, the subsidy.

We collect these allegations on the Work Stop Date and Work Expenses for Disability application screen in MAPS (see MSOM INTRANETMAPS 005.008).

14. Work-related expenses for blind and disabled Medicare beneficiaries

We exclude some earned income if an individual (and spouse if the couple lives together) under age 65 receives Title II benefits based on blindness or disability, works, and alleges work-related expenses which are not reimbursed. For earned income exclusions, see HI 03020.030.

We collect allegations about work-related expenses on the Work Stop Date and Work Expenses Disability application screen in MAPS (see MSOM INTRANETMAPS 005.008).

15. Medicare Savings Programs

For the purpose of helping the claimant (and spouse if the couple lives together) apply for help from their State with their Medicare costs, unless the claimant opts out, we will send information from the application to the claimant’s State to initiate the Medicare Savings Programs application process.

We record the Medicare Savings Programs decision on the Medicare Savings Plan application screen in MAPS (see MSOM INTRANETMAPS 005.013).

16. Signature

IMPORTANT: The claimant (and spouse if the couple lives together) should sign and date the application using one of the signature methods in GN 00201.015. (For a detailed explanation of using signature proxy for subsidy applications, see HI 03010.038D in this section). However, if:

• The claimant cannot sign and a personal representative assisted with the application, we will process the application with the personal representative's signature (see HI 03010.010B); or

• Only one spouse is available at the interview, that spouse can sign (using proxy) for the other spouse as the other spouse's personal representative. Do not mail an application simply to obtain an ineligible spouse's signature; or

• The FO or Workload Support Unit (WSU) receives a systems-generated SSA-1020-OCR without a signature, forward the form to WBDOC per HI 03010.038B.2. in this section. Do not return the form to the applicant(s) for a signature.

17. Mailing address

We use the claimant’s mailing address to mail correspondence to the claimant.

For collecting address information in MAPS, see MSOM INTRANETMAPS 005.010.

If there is a change of address indicated within the last three months, follow the POS Title II procedures to update the MBR (see MSOM T2PE 003.001). If for some reason a Supplemental Security Income (SSI) recipient submits an SSA-1020-OCR, even though automatically deemed eligible for the Extra Help, follow normal procedures to update the supplemental security record (SSR). (The WBDOC will process, as exceptions, address changes indicated on the i1020 and SSA-1020-OCRs that the WBDOC receive by mail).

18. Section B of the signature page

A personal representative who helped the claimant complete the application answers this section. For an in-office interview or teleclaim with a personal representative, the interviewer should enter the information about the personal representative.

To help us target future outreach efforts better, we ask that you follow these guidelines when you place an [X] inside a box:

• Family Member refers to anyone related to the beneficiary by blood or marriage.

• Friend is a non-relative helping the beneficiary in a nonprofessional capacity.

• Attorney only refers to the claimant's own legal representative. Attorneys who are not the claimant's own legal representative should select another box.

• Agency (government) refers to a government caseworker who completes the application as part of a public assistance effort. If you complete the application on behalf of a State pharmaceutical assistance program, see the following bulleted item marked “Other.”

• Other Advocate means someone completing the application at a Senior Center or other public facility who is not a caseworker or a social worker.

• Social Worker is someone who completes the application as part of their mission for the protection and advocacy of those in need.

• Other is for anyone not described above. When you place an [X] in the box next to Other, please use the following exact letters to describe your role in helping with this application:

D. Use of signature proxy

Signature proxy applies to all three versions of the subsidy application. We use attestation and witnessed signatures for the MAPS application and SSA-1020-OCRs completed by the FO or WSU when MAPS is not available. Internet (i1020) filers use an electronic signature, “click and sign”, as the alternative signature method.

FOs and WSUs should use the following guidelines when completing the application:

1. Claims interviewer responsibilities

1. Explain that the interviewer will confirm the applicant's intent to file, affirmation under penalty of perjury that the information provided is correct, and agreement to sign the application for Extra Help. The interviewer's annotation of the ATTEST issue on the DWAT (see MSOM INTRANETMAPS 006.007) constitutes a signed application.

2. Complete and print the MAPS application and give it to the applicant (or mail it if a teleclaim was taken) for review and retention, along with an application receipt. There are no signature proxy cover notices for the Part D subsidy to accompany the application and receipt.

3. Advise the applicant to contact SSA within 10 days of receiving the completed application to make any corrections.

NOTE: In order to have the application stored in the Online Retrieval System, you must always print the MAPS application.

2. Attestation of interviewer's script for in person claims

a. Start of the interview

“During this interview, we will ask you questions that will be used to process your/or name of your spouse's application for Extra Help with Medicare prescription drug costs. At the end of the interview, we will ask you to confirm the truthfulness of your answers under penalty of perjury and we will record your response. You should be aware that you can be held legally responsible for giving us false information.”

b. End of the interview and review of printed output

“Here is a printed copy of the information that will be used to process your/or name of your spouse's application. Please review all the information carefully and let us know right away if anything needs to be corrected OR if any of the information changes.”

c. Obtain claimant's affirmation of intent to file and understanding of penalty clause

“Do you understand that the information you gave us and examined will be used to process your/or name of your spouse's application for Extra Help with Medicare prescription drug costs? Do you declare under penalty of perjury that this information is true and correct to the best of your knowledge?”

3. Attestation of interviewer's script for teleclaims

a. Start of the interview

“During this interview, we will ask you questions that will be used to process your/or name of your spouse's application for Extra Help with Medicare prescription drug costs. At the end of the interview, we will ask you to confirm the truthfulness of your answers under penalty of perjury and we will record your response. You should be aware that you can be held legally responsible for giving us false information.”

b. End of the interview and review of printed output

“You will receive a printed summary copy of the information used to process your/or name of your spouse's application to retain for your records. Do you understand that you must review all of this information carefully and let us know right away if anything needs to be corrected OR if any of the information changes?”

c. Interviewer's script to obtain claimant's affirmation of intent to file and understanding of penalty clause

“Do you understand that the information you have provided will be used to process your/or name of your spouse's application for Extra Help with Medicare prescription drug costs? Do you declare under penalty of perjury that this information is true and correct to the best of your knowledge?”

4. MAPS applications signed via witnessed signature

In an in-person or teleclaim situation, if an applicant insists on signing the MAPS application via pen-and-ink, obtain the signature on the printed application. In teleclaim situations, use the cover letter SSA-L825 (Person Requests Application to Sign Medicare Subsidy Application) in the General Folder on Document Processing System (DPS) to send the application for signature.

REMEMBER: In a teleclaim situation, until we receive a signed application, the date the application process started serves as a protective filing date which must be closed out in accordance with instructions in HI 03010.020.

Once we have a signed application, provide the applicant with a claim receipt. Receipt the ATTEST issue on the DW01 to indicate that the application was signed with a pen-and-ink signature.

5. Taking paper applications when MAPS is not available

If MAPS is not available to take a subsidy application, use the paper scannable SSA-1020-OCR. In an in-person interview, obtain a pen-and-ink signature from the applicant. In a teleclaim, follow HI 03010.038D.3. in this section and annotate the signature line with the word “Proxy” and your initials. Do not mail the application to the applicant for a signature in a teleclaim unless the applicant insists on signing via pen-and-ink. Forward the completed SSA-1020-OCR to the WBDOC for imaging and processing.

6. Processing MAPS applications when answers are unknown

If the applicant does not know the answer to all question(s):

• Obtain the applicant's proxy signature for the partially completed MAPS claim following the procedures in HI 03010.038D.2.c. in this section or HI 03010.038D.3.c. in this section;

• Record on the Report of Contact screen (see MSOM INTRANETMAPS 006.003) under Comments, “Proxy received MM/DD/YY: unanswered question(s) on _________ screen (insert the four character screen abbreviation)”; and

• Obtain the applicant's proxy signature again on the signature page following the procedure in HI 03010.038D.2.b. and HI 03010.038D.2.c. or HI 03010.038D.3.b. and HI 03010.038D.3.c. in this section when the applicant provides the answers.

E. Procedure for receipt for the application

We will issue a receipt to the claimant upon filing an application. The type of receipt issued will depend on the method of filing.

For information about printing the MAPS application receipt, see MSOM INTRANETMAPS 005.012.

F. Unenumerated individuals

IMPORTANT: Needing a Social Security number (SSN) solely to file for Extra Help with Medicare prescription drug plan costs is not a valid reason for assigning an SSN. (To determine if the individual has a valid nonwork reason, see RM 10211.600 through RM 10211.620 and RM 10211.500 through RM 10211.505).

1. Unenumerated applicant

If the applicant does not have his or her own SSN, and you cannot locate a number through an alpha search, follow the procedures in RM 10210.010 (Evidence Policy for an Original or New SSN) to determine if you can assign a number.

2. Unenumerated spouse

If the applicant’s spouse does not have his or her own SSN and you cannot locate a number through an alpha search, follow the procedures in RM 10210.010 (Evidence Policy for an Original or New SSN) to determine if you can assign a number.

If you cannot enumerate the spouse (e.g., he or she is not legally present in the U.S.), complete the application as follows:

• Explain the situation on an RC (DWRC).

• Do not list the spouse on the application.

• Do not answer any “spouse” questions on the application.

• Add all of the spouse's income to the applicant's income.

• Increase the household size by one to compensate for the spouse.

Input resources as follows in 2018:

G. Exhibit of the SSA-1020B-OCR-SM (Application for Extra Help with Medicare Prescription Drug Plan Costs)

This is an exhibit of the scannable subsidy application. Do not reproduce or use the exhibit; it is not an actual application.

http://mwww.ba.ssa.gov/forms/ssa-1020b-ocr-sm-inst.pdf