Medicare Prescription Drug Assistance
Program Service Center
Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
We are changing the amount of the extra help you get with Medicare prescription drug
plan costs. The rest of this notice explains how we figured the change, when it will
change, what information was used to make this decision, what to do if your situation
changes, and your appeal rights.
Your Help Will Change
You will receive increased help, also known as the subsidy, because of a change in
your income. Beginning January 2007, you are eligible for:
75% subsidy to help pay your Medicare prescription drug plan premiums;
Reduced prescription drug annual deductible; and
Reduced co-payment amounts when you have a prescription filled.
Information Used To Determine Your Eligibility
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:
Your resources we count are less than $6,000. 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 no income.
What To Do If Your Situation Changes
If your mailing address changes, report it to us right away by calling toll-free 1-800-772-1213.
Certain changes in your situation may affect the amount of extra help you can receive
to pay for your prescription drug plan costs. You can contact Social Security to tell
us if any of the following changes happens.
you and your spouse who lives with you divorce;
your spouse who lives with you dies;
you and your spouse separate;
you and your spouse have your marriage annulled; or
you and your separated spouse begin living together again.
If You Disagree With The Decision
If you disagree with the decision, you have the right to appeal. We will provide you
with a hearing by telephone or a case review. We will look at any new information
you have. The person who will conduct the hearing or case review had no prior involvement
in the first decision. We will review those parts of the decision which you believe
are wrong and will look at any new facts you have. We may also review those parts
which you believe are correct and may make them unfavorable or less favorable to you.
If you want this appeal, either by a hearing or a case review, you may request it
by calling toll-free 1-800-772-1213.
You have 60 days to ask for an appeal.
The 60 days start the day after you get this letter. We assume you got this letter
5 days after the date on it unless you show us that you did not get it within the
You must have a good reason for waiting more than 60 days.
You can call to request an appeal. You can also obtain a copy of the form SSA-1021,
“Request for Appeal of Determination for Help with Medicare Prescription Drug Plan
Costs” from www.socialsecurity.gov. Contact us if you need help.
If You Want Help With Your Appeal
You can have a lawyer, friend, or someone else help you. Your local Social Security
office has a list of groups that can help you. These groups can 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.
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.
If you do call, please have this letter with you. It will help us answer your questions.