Effective Dates: 01/19/2024 - Present Previous | Next

TN 7 (01-24)

HI 03040.200 Appeal Processing

CITATIONS:

20 CFR 418.3605 - 418.3680

A. Policy

1. Opportunity to Review File

The subsidy determination and appeal file are electronic. The individual, upon request, is entitled to a copy of all the information in their file. If an individual asks to review their file, refer the individual to the appropriate Subsidy Appeals Unit (SAU). See HI 03040.100B.3. The SAU will contact the local Field Office (FO) to make the arrangements and recontact the individual to let them know when it is possible.

The file will include information shown in Medicare Application Processing System (MAPS), a copy of the initial determination, and information in records available to SSA, etc. Follow disclosure policy in GN 03300.000.

2. Time of Hearing and Good Cause

Individual/representatives and witnesses should be available at least 15 minutes before the time scheduled for the hearing. The times will be shown on the Notice of Hearing Appointment. Agree to the first request for postponement for any reason and to additional requests if there is good cause. If the individual is not available at the time of the phone hearing or did not request a postponement, the Subsidy Determination Reviewer (SDR) will wait 2 days to see if the individual contacts us before conducting a case review based on the information in the file plus any additional information provided, and will send the notice of decision.

For examples of some reasons for missing the scheduled hearing, see HI 03040.001C.2.b.

3. One Hearing for Members of Couple

If an individual and their living-with spouse both file an appeal, each will receive a notice of decision. At the time the SDR schedules the appeal, the SDR may ask whether the couple agrees to one combined phone hearing in which case one appointment notice may be sent. If each wishes to have their own hearing, two appointment notices are required.

4. Additional Information Documentation

Additional information is documented on the Report of Contact (DWRC) screen in MAPS. Photocopies are acceptable and should be destroyed after the information is documented in MAPS. Original documents are returned to the individual. Destroy facsimiles.

If additional information is received without a written request for appeal, it will be treated as an implied request for appeal. Contact the individual to get information for completing the Appeal Application Screens in MAPS. If the individual cannot be reached, complete as much as necessary of the Appeal Application Screens to submit to the SAU.

5. Telephone Hearing Continuation

If a SDR fails to cover all of the issues or obtain all of the information at the time of the hearing and another call to the individual is necessary, record any additional calls. A continued hearing would be one in which the first hearing was postponed or delayed for some reason, e.g., a power outage cut the call short or an emergency occurred during the hearing so that it had to be postponed. All telephone hearings including continued hearings will be recorded in case there needs to be a transcript made at a later date. Document the reasons for the additional calls and continued hearing on the DWRC screen in MAPS.

6. Subpoena Witnesses

When determined to be reasonably necessary for the full presentation of a case, a subpoena may be issued to compel the production of certain evidence or testimony. A subpoena is not necessary for those witnesses who wish to participate in the hearing. See SI 04020.050 for information on use of a subpoena.

7. Dismissal

a. Pre-Decisional Determination

Taking an appeal on a pre-decisional determination is inappropriate and cannot be entered into MAPS. The pre-decisional is not an initial determination and the notice does not contain appeal rights.

  • •

    When an individual contacts the 800 number or the field office as a result of the pre-decisional notice, make all necessary changes to the initial application and submit to subsidy determination.

  • •

    If an individual submits a paper SSA-1021 to the field office or Wilkes-Barre Direct Operations Center (WBDOC) based on a pre-decisional notice, the employee will verify the additional or updated information; make the changes in MAPS, and complete case processing by submitting the updated information to subsidy determination. Immediately fax the paper SSA-1021 to the Woodlawn, Maryland SAU (fax no. 410-594-2066) to process the dismissal.

  • •

    Batch the paper SSA-1021s at the end of each day and mail the batch to: Medicare Subsidy Appeals Unit, P.O. Box 17720-7720, Baltimore, MD 21235. The Woodlawn Subsidy Appeals Unit will send the individual a dismissal notice. Pre-decisional issues policy is captured in subchapter HI 03035.000.

  • •

    The SAU will wait until the notice of denial/award is released. Contact the individual to determine whether they wish to continue with the appeal and handle accordingly.

b. Dismissal of Appeal on Initial Determination

Only the SAU may dismiss an appeal. It is important that care is taken to ensure that the dismissal is appropriate. Once an appeal is dismissed, the individual loses their right to appeal.

We will mail a written notice of the dismissal to the individual at their last known address. The notice will include the reason for the dismissal and the effect of the dismissal on the individual’s subsidy if the individual is receiving a subsidy. For example, the individual was receiving a subsidy and receives a notice that it is being terminated as a result of a subsidy changing event. The individual appeals the termination and the appeal is dismissed for lack of good cause for late filing. The notice will explain that the individual's subsidy will terminate.

Some dismissal reasons include:

  • •

    Issue appealed is not an initial determination

  • •

    Individual did not file an application for a subsidy

  • •

    Individual requesting appeal is not proper party. Before dismissing the appeal, attempt phone contact with the applicant to determine if they want to appeal.

  • •

    Individual failed to request administrative review timely and did not have good cause for missing the deadline for requesting review.

  • •

    Individual dies while the appeal is pending and was not enrolled in a prescription drug plan (PDP) or Medicare Advantage with prescription drug coverage (MA-PD).

    NOTE: 

    SSA will not dismiss the request for appeal if we find that the individual is eligible for a subsidy or has been paying a Part D premium whether through Social Security benefit deduction or out-of-pocket. The SDR will issue a decision and send to last known address.

  • •

    An appeal was taken in error.

    •  

      The dismissal is binding unless it is vacated by a SDR supervisor. A SDR supervisor may vacate any dismissal of a request for appeal if, within 60 days after the date the individual receives the dismissal notice, they request that the dismissal be vacated and shows good cause why the request should not be dismissed.

    •  

      If an individual contacts the FO or calls the national 800 number to request vacating the dismissal, refer the caller to the SAU. See HI 03040.100B.3.

8. Disqualification of Subsidy Determination Reviewer (SDR)

The SDR conducting the hearing will not conduct the telephone hearing if they are prejudiced or partial with respect to any party or has any interest in the matter pending for decision. The SDR supervisor will decide whether to proceed with the telephone hearing or to appoint another person to conduct the hearing.

B. Process - Subsidy Appeal Unit Overview

Case Review

Telephone Hearing

  1. 1. 

    Case Review

    • •

      SDR conducts case review

    • •

      Inputs eligibility data (income, resource, etc) in MAPS

  2. 2. 

    Post Review Activities

    • •

      SDR prepares and sends the Notice of Decision,

    • •

      FAX COA to FO for necessary action

    • •

      SDR generates the list of exhibits

    • •

      SDR inputs the decision
  1. 1. 

    SDR schedules/reschedules appointment

  2. 2. 

    SDR sends Appointment Notice

  3. 3. 

    Pre-Hearing Review

    SDR reviews file

  4. 4. 

    Hearing

    • •

      SDR conducts phone hearing, documents names of those participating in hearing, records and documents record of hearing using identification information (appellant’s name, SSN, etc)

    • •

      Inputs eligibility data (income, resources, etc) in MAPS

  5. 5. 

    Post Hearing Activities

    • •

      SDR prepares and sends the Notice of Decision

    • •

      FAX COA to FO for necessary action

    • •

      SDR generates the list of exhibits

    • •

      SDR inputs the decision

The 800 number agent, FO, and WBDOC is responsible for inputting the correct appeal information in MAPS and submitting the request along with any related information to the SAU.

The SDR is responsible for processing the appeal including making the good cause determinations, sending an appropriate notice, and correcting any errors.

The SDR will complete processing as expeditiously as possible.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0603040200
HI 03040.200 - Appeal Processing - 01/19/2024
Batch run: 01/19/2024
Rev:01/19/2024