BASIC (05-05)

HI 03094.745 Reversal - Hearing

A. Purpose/Use

The “Reversal—Hearing” notice is sent for an appeal reversal determination 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: November 23, 2006

                                                            Social Security Number: 123-00-6789

JOHN Q. PUBLIC

123 MAIN ST

SPRINGFIELD OH 45501

On your request for appeal filed April 20, 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.

History

Your claim was previously denied on April 1, 2006. A hearing was held on May 10, 2006. You participated in the hearing.

Issue

The issue(s) in this case is whether you have another pension of $12,000 per year.

Facts

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.

The Decision

You are eligible for extra help to pay your Medicare prescription drug costs, also known as subsidy, based on the amount of your income. You will receive another notice explaining the amount of your subsidy.

Authority

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

And: