BASIC (05-05)

HI 03094.205 Pre-Decisional

A. Purpose/Use

The Pre-decisional Notice is sent out prior to a denial notice when an applicant appears to be ineligible for a subsidy. The notice tells the applicant he has 10 days to contact us if any of the information contained in the notice is incorrect. The pre-decisional notice is not a formal determination and does not contain appeal rights. This notice is produced by MAPS.

B. Sample Pre-Decisional Notice

Social Security Administration

Medicare Prescription Drug Assistance

Pre-Decisional Notice

                                                                                           Great Lakes Program Service Center

                                                                                           600 West Madison Street

                                                                                           Chicago, Illinois 60661-2474

                                                                                              Date: November 1, 2005

                                                                                            Social Security Number: 123-00-6789

JOHN Q. PUBLIC

123 MAIN ST

SPRINGFIELD OH 45501

A review of our records shows you may not be eligible for extra help with Medicare prescription drug plan costs.

The rest of this letter explains why we believe you may not be eligible, the information we plan to use to determine your eligibility, and what you need to do if the information in our records is incorrect.

Why You May Not Be Eligible For Help With Your Prescription Drug Plan Costs

You may not be eligible for a subsidy to help pay your Medicare prescription drug plan costs because both your resources and income are above the limit established by law.

Information Used In Making The Decision

When you are married and live with your spouse, we count the resources and income for both of you when we determine your eligibility for this extra help.

You have the following resources:

  • Cash

  • Bank accounts.

Your resources we count are more than $20,000. The enclosed worksheet shows you how we counted your resources.

You have 5 persons in your household. When we determine the size of your household, we count you, your spouse who lives with you, and any relative who lives with you and receives one-half support from you or your spouse.

You have the following yearly income:

  • Other Income of $25,000

  • Your spouse’s wages of $4950

Your income we count is 150% or more of the Federal Poverty Level. The enclosed worksheet shows you how we counted your income.

If You Disagree With Our Records

If you disagree with the information in our records, you must contact us within 10 days from the date you receive this notice. You may call us toll-free at 1-800-772-1213 or call or visit the local field office shown below. If you do not contact us within 10 days, your claim will be denied.

If You Are Not Correcting Any Information

If the information in our records is correct, you do not need to do anything. If you do not reply within 10 days, we will send you a formal notice denying your Application for Help With Medicare Prescription Drug Plan Costs.

How To Sign Up For A Medicare Prescription Drug Plan

You do not need to receive this extra help paying for the costs related to your Medicare prescription drug plan in order to be eligible to enroll in a Medicare prescription drug plan or Medicare Advantage drug plan. You can enroll beginning November 15, 2005. For more information about the prescription drug plans available in your area, go to www.medicare.gov on the Internet or call toll-free 1-800-MEDICARE (1-800-633-4227). If you are deaf or hard of hearing, you may call the Medicare TTY number toll-free at 1-877-486-2048.

If You Have Any Questions

For information about Medicare prescription drug plans or other Medicare issues, visit www.medicare.gov on the Internet or call toll-free 1-800-MEDICARE (1-800-633-4227). If you are deaf or hard of hearing, you may call the Medicare TTY number toll-free at 1-877-486-2048.

For information about the extra help with the costs related to Medicare prescription drug plans or general information about Social Security, visit our website at www.socialsecurity.gov on the Internet. You may also call Social Security toll-free at 1-800-772-1213. If you are deaf or hard of hearing, you may call our TTY number toll-free at 1-800-325-0778. We can answer most questions by phone.

You can also write or visit any Social Security office. The office that serves your area is located at:

                                                                                    Social Security

                                                                                    2026 W. Main St.

                                                                                    Springfield OH 45501

                                                                                    Telephone: 937-325-0674

If you do call or visit an office, please have this letter with you. It will help us answer your questions.

Regional Commissioner

Enclosure(s):

Resource Worksheet

Income Worksheet


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0603094205
HI 03094.205 - Pre-Decisional - 07/07/2006
Batch run: 01/27/2009
Rev:07/07/2006