TN 33 (08-23)

GN 02610.067 Sample Manual Notice of Award When Applying The AR After Title XVI Offset Was Applied - Exhibit

EXAMPLE

Social Security Administration

Supplemental Security Income

Notice of Award

This is to notify you that you are eligible to receive Supplemental Security Income payments under the provisions of Title XVI of the Social Security Act. The rest of this letter will tell you more about our decision.

Information About Medicaid

Since you are not eligible now for SSI, you are also not eligible for Medicaid based on SSI. However, if you need help with medical bills, you may still be eligible for medical assistance. Also, you may be eligible for Medicaid for the months we paid you SSI. Contact the local Department of Social Services for information about your State's medical assistance programs and your eligibility for Medicaid. When you visit that agency, please take this letter with you.  It will help the people there answer your questions.

Information About Your Payments

We are sending you a check for $3.00. This is money due you for August 1992 through October 1992.

Your Payment Is Based On These Facts

You were disabled August 1992 on.

You were living in the State of         for August 1992 on.

You have monthly income which must be considered in figuring your payment as follows:

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  Your Social Security benefits—before deductions for Medicare premiums, if any—of $610.00 for August 1992 on.

Because of your income, you are not eligible to receive SSI payments for November 1992 on.

Information About Your Back Payments

We are sending you an SSI check for $3 in December 1992. We will not count the part of this money which was due for back payments as your resource for 6 months. If the money is not spent before July 1, 1993, we will count any money left over as part of your resources. But things bought with this money may count as resources the month after they are bought. Your Social Security office can tell you which things count as resources. You cannot get SSI if the resources we count have a value of more than $2,000.00.

Things To Remember

If you think payment may be due you for earlier months or at anytime in the future, please contact us immediately. If you are not eligible to receive payment during a month before December 1993, you will have to file a new application to receive payment. Since we cannot make payments for a month before the month in which an application is filed, a delay in applying will result in a loss of payment for any months in which you are otherwise eligible.

Do You Disagree With The Decision?

If you disagree with this decision, you have the right to appeal. A person who did not make the first decision will decide your case. We will review those parts of the decision with which you disagree and will look at any new facts you have. We may also review those parts with which you agree and may make them unfavorable or less favorable to you.

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  You have 60 days to ask for an appeal.

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  The 60 days start the day after you receive this letter.

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  You must have a good reason if you wait more than 60 days.

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  To appeal, you must fill out a form called "Request for Reconsideration." The form number is SSA-561. To get this form, contact one of our offices. We will help you fill out the form.

How To Appeal

There are two ways to appeal. You can pick the one you want. If you meet with us in person, it may help us decide your case.

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  Case Review.  You have the right to review the facts in your file. You can give us more facts to add to your file. Then we will decide your case again. You will not meet with the person who decides your case. This is the only kind of appeal you can have to appeal a medical decision.

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  Informal Conference.  You will meet with the person who decides your case. You can tell that person why you think you are right. You can give us more facts to help prove you are right. You can bring other people to help explain your case.

If You Want Help With Your Appeal

You can have a friend, lawyer or someone else help you. There are groups that can help you find a lawyer or give you free legal services if you qualify. There are also lawyers who do not charge unless you win your appeal. We have a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must approve the fee before they can collect it.

If You Have Any Questions

If you have any questions, you may call, write, or visit any Social Security office. If you call or visit our office, please have this letter with you and ask for        .  The telephone number is        .

Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

                                      Signature

                                      Name of Manager

                                      Title