TN 15 (09-17)

A. Description of the SSA-1026-OCR-SM-SCE and SSA-1026-OCR-SM-REDE forms

The SSA-1026-OCR-SM-SCE (Social Security Administration Reporting A Change That May Affect Your Extra Help) and SSA-1026-OCR-SM-REDE (Social Security Administration Review of Your Eligibility for Extra Help) are self-help forms. The forms are the same and titled Statement for Continuing Eligibility for Extra Help with Medicare Prescription Drug Plan Costs; the cover letters are different:

1. We use the SSA-1026-OCR-SM-SCE:

   1. After the report of a subsidy-changing event (SCE) from a beneficiary or other source; with

   2. A 90-day response time. Beneficiaries can request an additional 30 day extension.

2. We use the SSA-1026-OCR-SM-REDE:

   1. After a report of an Other Event from a beneficiary or other source,

   2. For initial redeterminations,

   3. For cyclical redeterminations, with

   4. A 30-day response time. Beneficiaries can request an additional 30-day extension.

Both the SSA-1026-OCR-SM-SCE and the SSA-1026-OCR-SM-REDE ask the beneficiary to confirm the information SSA has on the Resources and Income Summary Sheet that is included with the form. We ask the recipient to tell us about changes only.

B. Process the SSA-1026-OCR-SM-SCE and SSA-1026-OCR-SM-REDE forms

The nightly batch Medicare notice process prepares an electronic file for the contractor containing all the SSA-1026-OCR-SM-SCE and SSA-1026-OCR-SM-REDE data records to print the appropriate form for mailing.

We mail redetermination forms to the beneficiary with a postage-paid return envelope. Each form has different cover letters and:

• Includes the cover instructions explaining that this is for a redetermination of eligibility; and

• Has information in the barcode to distinguish the type of redetermination.

The beneficiary returns the form in the enclosed postage-paid envelope to the Wilkes-Barre Direct Operations Center (WBDOC). Once WBDOC (or the field office (FO), if it gets the case and the case is subject to exception or verification processing) processes the SSA-1026-SCE or the SSA-1026-REDE form, the beneficiary will receive a notice advising him or her of the results of the review:

• No change in the subsidy amount;

• Increase in the subsidy amount;

• Decrease in the subsidy amount; or

• Termination.

C. Process the SSA-1026B (bulk redetermination forms)

We send a small supply of bulk redetermination forms (SSA-1026B-OCR-SM (Statement for Continuing Eligibility for Extra Help with Medicare Prescription Drug Plan Costs) to all FOs in case a beneficiary or personal representative walks into the office, requests a form, and is not able to stay to complete the form with an FO representative. These forms do not have a Resources and Income Summary sheet attached. The SSA-1026B-OCR-SM includes a return envelope to the WBDOC.

The SSA-1026B has a preprinted “X” in the WBDOC exception box. When WBDOC receives the SSA-1026B, technicians scan the form into MAPS and the following actions are taken:

1. WBDOC checks the scanned image of the form to determine if the redetermination is an SSA-1026B.

2. If the form is an SSA-1026B, the clerk will obtain a Medicare query to determine if any type of redetermination (cyclical or SCE) is pending.

3. If an SSA-1026B indicates an SCE, WBDOC will transfer the case to the servicing FO for processing.

4. If a redetermination is pending, WBDOC will process any exceptions as usual, contacting the beneficiary as needed.

5. If no redetermination is pending on the most recent MAPS decision, as denoted on the query, WBDOC will transfer the redetermination resulting from the receipt of an SSA-1026B to the servicing FO.

6. WBDOC will complete a Report of Contact screen (DWRC) showing the reason for the transfer of the SSA-1026B to the FO, usually because of an SCE or no redetermination is pending. For additional details on the Report of Contact screen, see MS INTRANETMAPS 006.003.

7. The FO will contact the beneficiary, if necessary, to determine what action the beneficiary is reporting to the agency.

D. Exhibits of SSA-1026-OCR-SM-SCE and SSA-1026-OCR-SM-REDE forms

1. Social Security Administration Reporting A Change That May Affect Your Extra Help

Statement for Continuing Eligibility for Extra Help with Medicare Prescription Drug Plan Costs

SSA-1026-OCR-SM-SCE

2. Social Security Administration Reporting A Change That May Affect Your Extra Help in Spanish

Statement for Continuing Eligibility for Extra Help with Medicare Prescription Drug Plan Costs

SSA-1026-OCR-SM-SCE-SP

3. Social Security Administration Review Of Your Eligibility For Extra Help

Statement for Continuing Eligibility for Extra Help with Medicare Prescription Drug Plan Costs

SSA-1026-OCR-SM-REDE

4. Social Security Administration Review Of Your Eligibility For Extra Help in Spanish

Statement for Continuing Eligibility for Extra Help with Medicare Prescription Drug Plan Costs

SSA-1026-OCR-SM-REDE-SP

E. References

HI 03035.000 Verification Process and Pre-Decisional Issues

HI 03050.020 Redetermination of Eligibility for Medicare Part D Extra Help

(Low-income Subsidy)

HI 03050.025 Subsidy-Changing Event (SCE) and Other Event

HI 03050.030 Initial and Cyclical Redeterminations Process for Extra Help

HI 03050.040 Exception Processing for Form SSA-1026 Questions

HI 03050.045 Manual Correction Process for the Extra Help Application