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323-330 Subsidy Effective Date PIC 9(08) This is the effective date of the approved subsidy application. If the beneficiary is already enrolled in a plan and has Medicare, this will be the first month the beneficiary can use the Extra Help to save on his Medicare prescription drug expenses. Format: MMDDCCYY 331-347 Level of Resources PIC X(17) There are two resource limits in the LIS program. The lower level of resources provides greater assistance including help with co-pays. Values = Reduced Co-Pay or No Reduced Co-Pay 348-350 Income Used for Determination PIC X(03) Will display if income used was based upon an individual or from a couple. Values: SNG (Individual) or CPL (Couple) 351-353 Income as Percentage of FPL PIC X(03) Will display the percent of the Federal Poverty level for the income used on this subsidy determination. 354-356 Premium Subsidy % Of Subsidy Award PIC 9(03) Indicates the percent of premium subsidy awarded. This could be 0, 25, 50 or 100%. A 000 is the equivalent of a denial since 0% (nothing) has been awarded, and 050 would be a 50% partial subsidy award. Values: 000 (Nothing/Denial), 025 (25%), 050 (50%), 075 (75%), or 100 (100%) 357-359 Denial Reason Code 1 PIC X(3) If the case is denied, this is where SSA will show the reason(s). More than one code and the explanation may be shown, if applicable.

If the beneficiary does not or will not have Medicare during the life of the application, NAB is displayed in this field.

If the beneficiary does not provide necessary information requested by SSA needed to determine his/her eligibility, the denial code would be FTC for failure to cooperate. If the beneficiary is denied for excess income INC or for resources RES, these codes will be displayed in this field.

Values: NAB - Not a A/B Medicare Beneficiary FTC - Failure to Cooperate RES - Resources INC - Income 360-389 Denial Reason Description 1 PIC X(30) 390-392 Denial Reason Code 2 PIC X(3) 393-422 Denial Reason Description 2 PIC X(30) 423-425 Denial Reason Code 3 PIC X(3) 426-455 Denial Reason Description 3 PIC X(30) 456-458 Denial Reason Code 4

PIC X(3) 459-488 Denial Reason Description 4 PIC X(30) 489-496 Application Date PIC 9(08) This is the date of the application.

Format: MMDDCCYY