BASIC (05-05)

HI 03094.730 Affirmation - Case Review

A. Purpose/Use

The “Affirmation—Case Review” notice is sent for an appeal determination of an affirmation when a case review was conducted. This notice is created in the Document Generation System (DGS) used in the Subsidy Appeals Unit.

B. Sample Notice

Social Security Administration

Medicare Prescription Drug Assistance

Notice of Appeal Decision

SDS return address

Date: November 23, 2005

Social Security Number: 123-00-6789




On a request for appeal filed March 11, 2006, you asked us to review the determination we made on your Application for Help with Medicare Prescription Drug Plan Costs. This notice tells you our decision, the reason for our decision, and the effect our decision has on your right to further review.


Your claim was previously denied on February 28, 2006. A case review was conducted on April 14, 2006. The case review is based on the information in your file and any additional information you provided.


The issue(s) in this case is whether you have countable income that is 150% or more of the Federal Poverty Level.


You submitted and I reviewed a letter from Sunshine Printing Incorporated which stated your pension is currently $11,000 per year. This amount added to your Social Security benefits of $3,269 puts you over the income limit of $12,000 prescribed by law. Attached is a list of exhibits.

The Decision

You are not eligible for extra help to pay your Medicare prescription drug plan costs, also known as subsidy, because your income is over the income limit.


The new law on the Medicare prescription drug programs provides that the income and resource limits for eligibility for the Medicare Prescription Drug subsidy be based on our Supplemental Security Income (SSI) rules. I followed those rules in making this decision. You have the right to review and get copies of the information in our records that we used to make the decision explained in this letter. You also have a right to review and copy the laws, regulations and policy statements used in deciding your case. To do so, please contact us at 1-800-772-1213.

This Decision Is Final

If you disagree with the decision, you may ask for court review by filing a civil action. If you do not ask for court review, this decision will be final.

How To File A Civil Action

You may file a civil action (ask for court review) by filing a complaint in the United States District Court for the judicial district in which you live. The complaint should name the Commissioner of Social Security as the defendant and should include the Social Security number(s) shown at the top of this letter.

You or your representative must deliver copies of your complaint and of the summons issued by the court to the U.S. Attorney for the judicial district where you file your complaint, as provided in rule 4(i) of the Federal Rules of Civil Procedure.

You or your representative must also send copies of the complaint and summons, by certified or registered mail, to:

                    The General Counsel

                    Social Security Administration

                    Room 611 Altmeyer Building

                    6401 Security Boulevard

                    Baltimore, MD 21235


                   The Attorney General of the United States

                   Washington, DC 20530

Time To File A Civil Action

  • You have 60 days to file a civil action (ask for court review).

  • The 60 days start the day after you receive this letter. We assume you received this letter 5 days after the date on it unless you show us that you did not receive it within the 5-day period.

  • If you cannot file for court review within 60 days, you may ask us to extend your time to file. You must have a good reason for waiting more than 60 days. You must make the request in writing and give your reason(s) in the request.

You must mail your request for m