Initial determinations are the determinations we make that are subject to administrative and judicial review. The initial determination will state the important facts and give the reasons for our findings. Examples of initial determinations that are subject to administrative and judicial review include, but are not limited to, determinations on:

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  whether an individual is eligible for a subsidy; and

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  whether an individual receives a full or partial subsidy; and

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  reduction of an individual’s subsidy; and

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  termination of an individual’s subsidy.

  Note: 

  Starting January 1, 2024, the Inflation Reduction Act (IRA) provides full subsidy to all Extra Help beneficiaries. A partial subsidy determination can only be made on an Extra Help case that has a coverage start date before January 1, 2024.

All other administrative actions that are not initial determinations may be reviewed by us, but they are not subject to the administrative and judicial review process as provided by these sections. An example of a determination that is not an initial determination would be a change in an individual’s choice of a prescription drug program or a response to a pre-decisional notice.

The appeal process for subsidy determinations consists of one formal SSA administrative step. The individual can choose a hearing either by telephone or case review. Case review will be based on the information in the file and any additional information the individual or their personal representative provides. Both, the hearing by telephone or the hearing by case review are the same level of the administrative appeal process for subsidy determinations. If an individual is dissatisfied with SSA’s final decision, they may file an action in Federal district court.

It may be more advantageous to the individual to file an appeal than to file a new application, as the individual may lose one or more months of Part D subsidy by filing a new application. An appeal would preserve the retroactivity of the subsidy while a new application would not.

EXAMPLE: An individual files an application for Part D subsidy January 2006. The individual receives a denial notice dated February 3, 2006, but doesn’t appeal it and starts paying a premium for Part D. The individual then files a new application in May 2006 and is awarded the subsidy effective May 2006. If the individual had filed an appeal instead of a new application and the appeal decision was a reversal, the individual would have been eligible for a subsidy back to the month of the original application, January 2006.

Once an individual is receiving a subsidy and SSA proposes ending the subsidy, they qualify for automatic subsidy continuation when they appeal.

Individuals who qualify for subsidy continuation may choose to waive it. An individual can verbally request waiver. After waiving it, they may reconsider and receive it (including retroactive benefits) at any time before the appeal decision is final.

Individual Contacts SSA:

If the individual contacts the Field Office (FO), calls the national 800 number, or mails the appeal request to Wilkes-Barre Direct Operations Center (WBDOC), document the reason for late filing on the Good Cause for Late Filing screen in Medicare Application Processing System (MAPS).

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  Accept any reason the individual gives. If the request for appeal is filed late and good cause for late filing is established, automatic subsidy continuation is given.

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  If good cause is not established, the appeal is dismissed and the automatic subsidy continuation ends.

Development:

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  If contact with the individual is necessary to determine the reason for late filing, make two attempts and document on the Report of Contact (DWRC) screen in MAPS (date, time, phone number).

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  In addition, the Claims Specialist (CS) and only the CS, may include a recommendation based on their perception of the individual.

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  The case is submitted to the Subsidy Appeal Unit (SAU) for the good cause determination and release of appropriate notices.

Subsidy Appeal Unit:

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  The Subsidy Determination Reviewer (SDR) will complete the appropriate MAPS screens for subsidy continuation and good cause determination as well as the subsidy end date, if appropriate.

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  The MAPS Subsidy Continuation (DWSC) screen is removed from the MAPS application and the Determination Data History section of the MAPS Query will display, “Automatic Subsidy Continuation.”

See HI 03020.030D. if an eligible individual indicates they have a higher IRWE or BWE. Record the documentation in MAPS per HI 03010.040.

The individual or their personal representative (as defined in 42 CFR 423.772 and HI 03010.010B.) may request an appeal by calling the national toll-free 800 number or by calling, writing, or visiting any Social Security office. They can also obtain a copy of the SSA-1021 (Appeal of Determination for Help with Medicare Prescription Drug Plan Costs) from the internet. The mailing address on the form will be the address for WBDOC. There is no signature requirement and no signature proxy. See HI 03040.100 for establishing an appeal in MAPS.

The appeal method is a hearing by telephone unless the individual waives the hearing by telephone and agrees to a hearing by case review.

The 800 number agents, FO employees, and WBDOC establish the appeal by completing the Appeal Application screens in MAPS.

Once established, the case is submitted to the SAU in the Office of Earnings and International Operations (OEIO). The SDR in the SAU makes all appeal decisions.

Once the case is reviewed and decided by the SDR, the SDR will trigger the appeal decision notices through the Document Generation System (DGS).

The individual may also receive a notice from the subsidy determination process if there is a change in the subsidy eligibility.

See HI 03040.300C. for more information on appeal disposition notices.

If the caller has additional information to support the appeal, direct the caller to mail it to the SAU at the following address:

The appeal is a review of all facets of the determination not just those that the applicant found unsatisfactory. A new issue is an issue that was not considered in the initial determination. Where the SDR is deciding a new issue, the individual will be notified of the new issue being decided prior to the review. The SDR will add the new issue to the acknowledgment or appointment notice and when making their decision, the notice will include appeal rights.

Determine if the individual requesting an appeal is married and has a living-with spouse and whether the living-with spouse is also requesting an appeal.

If both spouses are requesting an appeal, MAPS establishes two appeals and both will receive a notice of decision.

If only one spouse appeals, but the other spouse’s eligibility for a subsidy is adversely affected by our decision upon review, the adversely-affected spouse will be sent a notice by the SDR prior to issuance of the decision, and given an opportunity to provide additional information.

Allow 15 days from the date notice is received for the spouse to respond.

If the spouse contacts the FO or calls the national 800 number requesting more information, follow HI 03040.100B.3. If the spouse asks where to submit additional information, provide the SAU address in HI 03040.001C.2. in this section.

If no response is received, process the request of the spouse who filed the appeal.

If the individual chooses not to have a hearing by telephone, it will be established in MAPS. The decision will then be made by a case review, i.e., the decision will be based on the information in the file and any additional information provided by the individual.

Administrative review must be requested within 60 days after the date the individual receives notice of the initial determination.

The date that the individual receives the notice is presumed to be 5 days after the date on the notice unless the individual can show us that they did not receive it within the 5 days.

If the timeframe is missed, the individual may ask us for more time to request a review.

The request for an extension must explain why it was not filed within the stated time period and the reason entered on the Good Cause for Late Filing screen in MAPS.

The SDR will determine whether the individual has good cause for missing the timeframe.

The SDR makes the decision and is responsible for sending the appropriate notice. See HI 03040.300C. for more detail on the decisional notices. In some situations, a second notice will be sent by the subsidy determination system.