Basic (05-05)

HI 03094.735 Affirmation - Hearing

A. Purpose/Use

The “Affirmation—Hearing” notice is sent for an appeal determination of an affirmation when a telephone hearing was held. 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 Hearing Decision



                                                           SDS return address

                                                                        Date: April 20, 2006

                                                                        Social Security Number: 123-00-6789









On a request for appeal filed March 25, 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 March 10, 2006. A hearing was held on April 20, 2006. You participated in the hearing along with John Smith.




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 more time to us at the address shown at the top of this notice. Please put the Social Security number(s) also shown at the top of this notice on your request. We will send you a letter telling you whether your request for more time has been granted.


How To Sign Up For A Medicare Prescription Drug Plan


You do not need to receive this extra help paying for the costs related to your Medicare prescription drug plan in order to be eligible to enroll in a Medicare prescription drug plan or Medicare Advantage drug plan. You can enroll beginning November 15, 2005. For more information about the prescription drug plans available in your area, go to 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.


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.


If you do call, please have this letter with you. It will help us answer your questions.



                                                                          Subsidy Determination Reviewer



List of Exhibits


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HI 03094.735 - Affirmation - Hearing - 05/24/2005
Batch run: 07/08/2013