Basic (05-05)

HI 03094.305 Planned Action

A. Purpose/Use

Notice of Planned Action is used in post-entitlement situations to notify recipient of a decrease in subsidy. The Notice of Planned Action is produced by MAPS.

A modified version of the Notice of Planned Action is sent following a post-entitlement appeal when the appeal results in a reduction in the subsidy. The modified version omits the appeals paragraphs.

B. Sample Notice of Planned Action


Social Security Administration

Medicare Prescription Drug Assistance

Notice of Planned Action


                                                                       Great Lakes Program Service Center

                                                                       600 West Madison Street

                                                                      Chicago, Illinois 60661-2474

                                                                       Date: October 4, 2006

                                                                       Social Security Number: 123-00-6789









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 reduced help, also known as the subsidy, because of a change in your income. Beginning January 2007, you are eligible for:


  • 25% 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 $10,000. 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:


  • Veterans benefits of $5420


Your income we count is between 140% and 144% of the Federal Poverty Level. The enclosed worksheet shows you how we counted your 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 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 5-day period.

  • 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 Contact us if you need help.


Appeal in 10 Days To Keep Getting The Same Help


  • We will not change the help you get if you appeal in 10 days.

  • The 10 days start the day you get this letter.

  • The help you get will be reduced only if your appeal is denied.


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 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 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



Resource Worksheet

Income Worksheet



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HI 03094.305 - Planned Action - 07/07/2006
Batch run: 07/08/2013