BASIC (05-05)

HI 03094.301 Change

A. Purpose/Use

Notice of Change is used in post-entitlement situations to advise recipient of an increase in the subsidy. The notice of change is produced by MAPS.

A modified version of the Notice of Change is sent following a post-entitlement appeal that either results in an increase in subsidy or no change in subsidy when payment continuation is involved. The modified version omits the appeals paragraphs.

B. Sample Notice of Change

Social Security Administration

Medicare Prescription Drug Assistance

Notice of Change

                                                                           Great Lakes Program Service Center

                                                                           600 West Madison Street

                                                                           Chicago, Illinois 60661-2474

                                                                           Date: December 1, 2006

                                                                           Social 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:

  • Bank accounts

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 get married;

  • 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 i