Prescription Drug Assistance
Great Lakes Program
600 West Madison
Date: October 4, 2006
Social Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
We can no longer give you extra help 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 Terminate
You will no longer be able to get extra help with your Medicare prescription drug
plan costs effective January 2007.
Why Your Help Will
Because of your resources and income, you are not eligible for extra help with your
Medicare prescription drug plan costs effective January 2007.
Information 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:
Stocks, bonds, or other investments.
Cash Value of Life Insurance
Your resources we count are more 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:
Net self-employment earnings of $2500.
Your income we count is 150% or more of the Federal Poverty Level. The enclosed worksheet
shows you how we counted your income.
What To Do If Your Situation Changes
If at any time in the future you think you qualify for this extra help, also known
as a subsidy, please contact us immediately about filing a new application.
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.
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 stop 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
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:
2026 W. Main St.
Springfield OH 45501
If you do call or visit an office, please have this letter with you. It will help
us answer your questions.