SSA-9301 Current Version

Form Approved
OMB No. 0960-0707

Social Security Administration

MEDICARE SUBSIDY - QUALITY REVIEW CASE ANALYSIS
1. QA Office Code:
Subsidy Level:

%

Sample Cycle:
Interview date:

Study ID:

2. Beneficiary’s (BN) SSN:
Living-with Spouse’s (LWS) SSN (If applicable):
Date Application Received:
3. Exclusion:
Yes
If yes, exclusion code:
Name of BN:

Other Contact:

Address:

Representative Payee (if applicable)
Name:

Phone: (

)

LWS:

Yes

Address:

LWS name:

Phone:

LWS contacted:

Third Party

Yes
Remarks:

)

Name:
Address:

Phone:
Remarks:

Form SSA-9301 (09-2015)
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SSA Records
1. Identity
SSN
BN:
LWS:

Interview
BN
SSN
Name on Record
Date of Birth
Birthplace
Parents

Date of Birth
BN:
LWS:
Remarks:

LWS
SSN
Name on Record
Date of Birth
Birthplace
Parents

Remarks:

Verification

Conclusion

1. Identity
SSN agrees with
systems queries
BN:
No

Proper BN/LWS interviewed
No
Remarks:

LWS:
No
Remarks:

Form SSA-9301 (09-2015)

Page 2

SSA Records
2. Marital Status
Single, Divorced,
Widow(er),
Married Not
LWS
Married LWS
Remarks:

Interview
What was your marital status at the time the application was filed?
Single, Divorced, Widow(er), Married Not LWS
Married LWS
Has there been any change in marital status since the application date?
Yes
If yes, indicate type of change below.
Divorce

Separation from Spouse

Annulment

Death of your Spouse

Marriage

Resumption of cohabitation
after separation

Date of change:
Remarks:

Verification

Conclusion

2. Marital Status (Verification not required)

LWS
Yes

Remarks:

Deficiency
Yes
Remarks:

Form SSA-9301 (09-2015)

Page 3

SSA Records
3. Family Size (FS)
Number of relatives
living with the BN/LWS
for whom they allege
providing at least ½
financial support:

Alleged FS
(include BN/LWS)

Remarks:

Interview
Household Composition
If BN or BN and LWS live alone, check the appropriate box.
BN lives alone
BN and LWS live alone
If BN or BN and LWS live with others complete the following:
Check all applicable boxes:
BN
LWS
Deemed children. Number:
Other related individuals. Number:
Unrelated people in the HH. Number:
Total number in household (HH) from boxes checked above
In the chart below, show the name, relationship, income and whether or not
½ support is alleged for each relative in the HH of the BN or LWS. (If none,
proceed to conclusion column for completion.)
RELATIONSHIP

NAME

INCOME

Average Monthly HH Expenses
Type
Amount
Type
Food
$_______
Gas
Rent
$_______
Electricity
Property
Property
Tax
$_______
Insurance
Water
$_______
Sewer
Mortgage
$_______
Heating/Fuel
Garbage
Removal
$_______
Total Average Monthly HH Expenses
Remarks:

Form SSA-9301 (09-2015)

Page 4

Amount
$_______
$_______
$_______
$_______
$_______
$_______

½ SUPPORT
ALLEGED
Yes
Deemed
Yes
Deemed
Yes
Deemed
Yes
Deemed
Yes
Deemed
Yes
Deemed
Yes
Deemed

Verification

Conclusion

3. FS
If BN or BN and LWS live alone, check the appropriate box.
BN lives alone
BN and LWS live alone

Total FS:
Difference
Yes

If BN or BN and LWS live with others complete the following:
Number of people in HH _____ (including the BN and LWS)
Pro rata share (total monthly expenses divided by number of people in
HH)________

Stand Alone Deficiency
Yes
Combined Deficiency
Yes

1/2 support not met for the following individuals.

Remarks:
1/2 support met for the following individuals.

1/2 support deemed for the following children.

Remarks:

Form SSA-9301 (09-2015)

Page 5

SSA Records
4. Liquid Resources (LR)
No Liquid Resources

Interview
Indicate the type(s) of liquid resources involved and the amount. Provide
the information needed to contact collateral sources.

Bank Accounts: $
Stocks, bonds, savings
bonds, mutual funds, IRA or
similar accounts:
$______
Cash: $______
Other:_____________
__________________
$_______
Computer Match:
BN
Source: _______________
Amount:$______________
Source: _______________
Amount:$______________
Source: _______________
Amount:$______________
Source: _______________
Amount:$______________
LWS
Source: _______________
Amount:$______________
Source: _______________
Amount:$______________
Source: _______________
Amount:$______________
Source : _______________
Amount:$______________

Cash
Checking Account
Savings Account
Cert. of Deposit
Mutual Funds
Credit Union Accts.
Other Bank Account
(Christmas Club, etc.)
Patient Accounts
Savings Bonds
Stocks/Bonds
Promissory Notes
401K Plans/Keogh
Accounts
Trusts
Other (Explain)
_________________

LWS

No LR

No LR

$________
$________
$________
$________
$________
$________

$_________
$_________
$_________
$_________
$_________
$_________

$________
$________
$________
$________
$________

$_________
$_________
$_________
$_________
$_________

$________
$________

$_________
$_________

$________

$_________

Account type: ___________ Account ID: ________________
Name of Source: _________________________________________
Address: ___________________________________________
___________________________________________
___________________________________________
Owner(s): ___________________________________
Balance: $________
Account type: ___________ Account ID: ________________
Name of Source: _________________________________________
Address: ___________________________________________
___________________________________________
___________________________________________
Owner(s): ___________________________________
Balance: $________
Remarks: ________________________________________________
_________________________________________________________

Remarks:

Form SSA-9301 (09-2015)

BN

Page 6

Verification

Conclusion
No Liquid Resources

4. Liquid Resources

Bank Accounts: $
(Checking, Savings, CD)

Evidence provided by BN:
Source document:
Account type:
Owner(s):
Balance: $
Source document:
Account type:
Owner(s):
Balance: $
Source document:
Account type:
Owner(s):
Balance: $

Account ID:

Stocks, bonds, savings
bonds, mutual funds, IRA
or other similar
Investments: $

Account ID:

Cash:

$

Other:

$

Total:

$

Account ID:

LR caused ineligibility.

Evidence provided by collateral contact:

Difference
Yes

Name of Source:
Address:

Stand Alone Deficiency
Yes

Account type:
Owner(s):
Balance: $

Account ID:

Combined Deficiency
Yes
Remarks:

Name of Source:
Address:

Account type:
Owner(s):
Balance: $

Account ID:

Name of Source:
Address:

Account type:
Owner(s):
Balance: $

Account ID:

Remarks:

Form SSA-9301 (09-2015)

Page 7

SSA Records

Interview

5. Non-home Real
Property (NHRP)

Allegation of NHRP ownership by BN/LWS:

Ownership:

Sole Ownership

Yes
CMV: $
Accurint NHRP lead
Yes

Yes

No

BN

LWS

Joint ownership
Joint owner’s Name:
Address:
Phone: (
Property Address:

)

Accurint NHRP lead for
LWS
CMV: $

Yes
Remarks:

Mortgage balance: $

Property Essential for Self-Support: $
Lien Holder:
Name/Source:
Address:
Phone: (
Encumbrances:

)

Sole ownership
BN

LWS

Joint ownership
Joint owner’s Name:
Address:
Phone: (
Property Address:

)

CMV: $
Property Essential for Self-Support: $
Lien Holder:
Name/Source:
Address:
Phone: (
Encumbrances:
Remarks:

Form SSA-9301 (09-2015)

Page 8

)

Mortgage balance: $

Verification

Conclusion

5. Non-Home Real Property

Non-Home Real Property:

Accurint produced no NHRP leads for BN
Accurint produced no NHRP leads for LWS

No NHRP
BN

Allegations verified by:

LWS

owns countable NHRP-Home

Government Records (e.g., Tax Assessment Statement)
Contact with applicable government records office (e.g.,
Assessor’s office)

Real Property with a total
equity value of: $ ________
BN
LWS

Date of contact:
Agency name:
Name of contact:
Address:

owns excludable NHRP-Home

Method of Contact

Real Property
Property Essential for
Self Support
Letter

Telephone

Internet

Other

Undue Hardship
Difference

Other (e.g. deed, sales contract, etc.)

Yes
Stand Alone Deficiency

Non-government collateral contact made

Yes

Name of Source:
Address:

Combined Deficiency
Yes

Method of Contact

Letter

Telephone

Internet

Other

NHRP found
Owner(s): ______________________________________
Verified CMV: $

Equity Value: $

Name of Source:
Address:
Encumbrances:

Property Essential for Self-Support: $
Remarks:

Form SSA-9301 (09-2015)

Page 9

Remarks:

SSA Records
6. Funeral/Burial Expenses
Funds expected to be used
for funeral or burial
expenses?
Yes

Interview
Funds expected to be used for funeral or burial expenses?
Yes
Remarks:

Remarks:

Verification
6. Funeral/Burial Funds
(Verification not required)

Conclusion
Exclusion does not apply
Exclusion applies
BN only
LWS only
Both
Difference
Yes
Note: Difference may affect total resource amount.
Remarks:

Form SSA-9301 (09-2015)

Page 10

Total Countable Resources Summary
Type of Resource

Total Value

Liquid Resources

$ __________

Non-Home Real Property

$__________

Subtotal

$__________

Minus Burial Fund Exclusion
(If applicable)

$__________

Total

$ __________

Resources caused ineligibility:

Yes

Remarks:

Form SSA-9301 (09-2015)

Page 11

SSA Records
7. Unearned Income (UI)

Interview
Indicate the type(s) of Unearned Income involved and provide the amount
and source of verification.

BN
No UI
Income type: ____________
Amount: $ ______
Income type: ____________
Amount: $ ______
Computer Match:
Source:_______________
Amount: $____________
LWS
No UI
Income type: ____________
Amount: $ ______
Income type: ____________
Amount: $ ______
Computer Match:
Source:_______________
Amount: $____________

Remarks:

Title II

LWS

No UI

No UI

$________

$_________

BN receives no other unearned income
LWS receives no other unearned income
Title XVI
Bank Deposits
VA Pension
VA Compensation
Gov’t Pension
Private Pension
Railroad Retirement
Black Lung
Educational Assistance
State Dib Payment
Unemployment
Worker’s Comp.
Sick Pay
Royalties
Rental Income
Gifts
Alimony
Patrimony
Gambling Proceeds
Child Support
Cash
Other
Source:
Name:
Address:
Phone:
Claim #:
Name:
Address:

$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________

$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________
$________

____________________________
____________________________
____________________________
( )__________________
______________________
____________________________
____________________________
____________________________
( )__________________
______________________

Phone:
Claim #:
Name:
Address:

____________________________
____________________________
____________________________
( )__________________
______________________

Phone:
Claim #:
Remarks
Form SSA-9301 (09-2015)

BN

Page 12

Verification

Conclusion

7. UI
Title II (verified by the MBR)
Title XVI (verified by the SSR - Informational only – not used for
subsidy determination )
Verified by award letter or other evidence in BN/LWS possession.
Source:___________________________________________
Address: ___________________________________________
___________________________________________
Phone: ( ) _________________

UI:
BN:
LWS:

Yes
Yes

Social Security: _______
Railroad Retirement: ______
Veterans: _______________

Total Yearly Amount:__________

Other pensions: __________

Source:___________________________________________
Address: ___________________________________________
___________________________________________
Phone: ( ) _________________

Other Income: ___________

Total Yearly Amount:__________

Difference

Source:___________________________________________
Address: ___________________________________________
___________________________________________
Phone: ( ) _________________
Total Yearly Amount:__________

Total Yearly Amount:__________
Source:___________________________________________
Address: ___________________________________________
___________________________________________
Phone: ( ) _________________
Total Yearly Amount:__________
Summary of Total UI (Drop all cents for monthly amounts of UI except
Social Security before converting to a yearly amount)

_____________
_____________

$____________
$____________

Total Yearly Unearned Income $_________
Remarks:

Form SSA-9301 (09-2015)

Stand Alone Deficiency
Yes
Combined Deficiency
Yes

Source:___________________________________________
Address: ___________________________________________
___________________________________________
Phone: ( ) _________________

Yearly Amount

$ _____________

Yes

Collateral contact made:

Type of Income

Total Yearly Countable UI

Page 13

Remarks:

SSA Records

Interview

8. Earned Income (EI)

BN currently working:

BN

If No, date last employed:_____________________________
No EI

LWS currently working:

Wages: $ _______
SEI

Yes

No

Stopped or plans to stop
work?
Yes
No
When? _________
Work expenses?
Yes

No

Computer Match:
$_________

BN

No EI
Wages: $ _______
: $ _______

Amounts decreased:

No EI
Wages
NESE
Sheltered Workshop Earnings
Royalties
Honoraria
In-Kind Earned Income

$_________
$_________
$_________
$_________
$_________
$_________

No EI
$_________
$_________
$_________
$_________
$_________
$_________

Source Name: _____________________________________
Address
: _____________________________________
_____________________________________
Phone
: ( ) ____________________

No

Source Name: _____________________________________
Address
: _____________________________________
_____________________________________
Phone
: ( ) ____________________
Explanation of increase or decrease in earnings: __________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

Stopped or plans to stop
work?
Yes
No

Cafeteria Plan

When? _________

IRWE/BWE

Work expenses?
Yes

LWS

Remarks:

LWS

Yes

Yes

If No, date last employed:_____________________________

: $ _______

Amounts decreased:

SEI

Yes

No

Yes

Work Expenses
Type(s): _______________________________________
Amount: $____________

Computer Match:

Frequency:

$_________

Remarks:

Weekly

Remarks:

Form SSA-9301 (09-2015)

Page 14

Monthly

Yearly

Verification

Conclusion
Neither BN
nor LWS has EI

8. EI and EI Exclusions
No EI

Wages
SEI

EI established:
Employer contact in file
Systems query (DEQY, SEQY)
Tax return
Copy of other business record

BN yearly countable EI:
$ _____________
LWS yearly countable EI:
$ _____________

BN’s pay stubs
Spouse’s pay stubs
Collateral contact made:
Source: ____________________________________
____________________________________
____________________________________
Date of Contact: ___________
Total: $______________________
Source: ____________________________________
____________________________________
____________________________________
Date of Contact: ___________
Total: $______________________
Work Expense(s) established:
IRWE

Weekly

Monthly

Yearly

Remarks: ____________________________________________
____________________________________________________

Form SSA-9301 (09-2015)

$ _____________
Difference
Yes
Stand Alone Deficiency
Yes
Combined Deficiency
Yes
Remarks:

BWE

Type: __________________________
Amount: $____________
Frequency:

Total Yearly Countable EI:

Page 15

Total Yearly Countable Income Summary
Unearned Income:

$ ___________

Earned Income:

$ ___________

Total

$ ___________

Income caused ineligibility or
affected the Subsidy Level:
Yes
________________
_________________
_________________
_________________

REMARKS/DEFICIENCY ANALYSIS

Form SSA-9301 (09-2015)

Page 16

REMARKS/DEFICIENCY ANALYSIS (continued)

Reviewer’s Signature:

Date:

Attach all Reports of Contacts, Available Documentation, Other Related Worksheets and
Continuation Pages.
Form SSA-9301 (09-2015)

Page 17