HI 03094.740 Reversal - Case Review
The “Reversal—Case Review” notice is sent for an appeal reversal determination 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: March 1, 2006
Social Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
On your request for appeal filed February 10, 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 January 25, 2006. A case review was conducted on March 1, 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 another pension of $12,000 per year.
You submitted and I reviewed a letter from Sunshine Printing Incorporated which stated your pension is currently $1100 per year. This amount added to your Social Security income of $7,200 does not put you over the income limit of $12,000 prescribed by law. Attached is a list of exhibits.
You are eligible for extra help to pay your Medicare prescription drug plan costs, also known as subsidy, based on the amount of your income. You will receive another notice explaining the amount of your subsidy.
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