Identification Number:
HI 03040 TN 7
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:Appeal of Medicare Part D Subsidy Determination
Type:POMS Full Transmittals
Program:Medicare,Medicaid
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part HI – Health Insurance

Chapter 030 – Eligibility for Subsidized Medicare Prescription Drug Coverage

Subchapter 40 – Appeal of Medicare Part D Subsidy Determination

Transmittal No. 7, 01/19/2024

Audience

PSC: BA, CA, CS, DS, IES, ILPDS, IPDS, ISRA, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, CR, CTE, EIE, ERE, FCR, FDE, PETL, RECONE, RECONR;
Subsidy Appeals Unit (SAU): SDR, SDS, SDT;
OCO-ODO: BET, BTE, CCE, CR, CST, CTE, CTE TE, DEC, DES, PAS, PETE, PETL, RECONR;
FO/TSC: CS, CS TII, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;

Originating Component

OISP

Effective Date

01/01/2024

Background

This transmittal provides new policy to support the legislative changes mandated in the Inflation Reduction Act of 2022 (IRA), Section 11404, which expands Medicare Part D Extra Help (Low Income Subsidy or LIS) full subsidy and ends Extra Help partial subsidy effective January 1, 2024.

 

Summary of Changes

HI 03040.001 Overview of Appeal Process for Medicare Part D Subsidy Determination

Subsection B: Added language about IRA change.

Revised this section to include Inclusive Language Initiative.

 

HI 03040.100 Appeal Establishment

Subsection B:

  • Deleted language regarding partial subsidy category.

  • Added language about IRA change.

  • Updated to include full address of the Subsidy Appeal Unit.

Revised this section to include Inclusive Language Initiative.

 

HI 03040.200 Appeal Processing

Subsection A:

  • Made minor language updates to improve clarity.

  • Deleted language regarding subsidy level amounts.

Revised this section to include Inclusive Language Initiative

HI 03040.001 Overview of Appeal Process for Medicare Part D Subsidy Determination

CITATIONS:

20 CFR 418.3605 - 418.3680

A. Introduction

SSA will make eligibility determinations based on an individual’s application for a subsidy. Notice of SSA’s subsidy determination will be mailed to the individual at their last known address. The notice will include appeal rights and explain how to request an appeal.

B. Policy

1. What Is an Initial Determination

Initial determinations are the determinations we make that are subject to administrative and judicial review. The initial determination will state the important facts and give the reasons for our findings. Examples of initial determinations that are subject to administrative and judicial review include, but are not limited to, determinations on:

  • whether an individual is eligible for a subsidy; and

  • whether an individual receives a full or partial subsidy; and

  • reduction of an individual’s subsidy; and

  • termination of an individual’s subsidy.

    Note: 

    Starting January 1, 2024, the Inflation Reduction Act (IRA) provides full subsidy to all Extra Help beneficiaries. A partial subsidy determination can only be made on an Extra Help case that has a coverage start date before January 1, 2024.

2. What Is Not an Initial Determination

All other administrative actions that are not initial determinations may be reviewed by us, but they are not subject to the administrative and judicial review process as provided by these sections. An example of a determination that is not an initial determination would be a change in an individual’s choice of a prescription drug program or a response to a pre-decisional notice.

3. Administrative Review Process for Subsidy Determinations

The appeal process for subsidy determinations consists of one formal SSA administrative step. The individual can choose a hearing either by telephone or case review. Case review will be based on the information in the file and any additional information the individual or their personal representative provides. Both, the hearing by telephone or the hearing by case review are the same level of the administrative appeal process for subsidy determinations. If an individual is dissatisfied with SSA’s final decision, they may file an action in Federal district court.

4. Filing a New Application versus Filing an Appeal

It may be more advantageous to the individual to file an appeal than to file a new application, as the individual may lose one or more months of Part D subsidy by filing a new application. An appeal would preserve the retroactivity of the subsidy while a new application would not.

EXAMPLE: An individual files an application for Part D subsidy January 2006. The individual receives a denial notice dated February 3, 2006, but doesn’t appeal it and starts paying a premium for Part D. The individual then files a new application in May 2006 and is awarded the subsidy effective May 2006. If the individual had filed an appeal instead of a new application and the appeal decision was a reversal, the individual would have been eligible for a subsidy back to the month of the original application, January 2006.

5. Subsidy Continuation During an Appeal

Once an individual is receiving a subsidy and SSA proposes ending the subsidy, they qualify for automatic subsidy continuation when they appeal.

Individuals who qualify for subsidy continuation may choose to waive it. An individual can verbally request waiver. After waiving it, they may reconsider and receive it (including retroactive benefits) at any time before the appeal decision is final.

Individual Contacts SSA:

If the individual contacts the Field Office (FO), calls the national 800 number, or mails the appeal request to Wilkes-Barre Direct Operations Center (WBDOC), document the reason for late filing on the Good Cause for Late Filing screen in Medicare Application Processing System (MAPS).

  • Accept any reason the individual gives. If the request for appeal is filed late and good cause for late filing is established, automatic subsidy continuation is given.

  • If good cause is not established, the appeal is dismissed and the automatic subsidy continuation ends.

Development:

  • If contact with the individual is necessary to determine the reason for late filing, make two attempts and document on the Report of Contact (DWRC) screen in MAPS (date, time, phone number).

  • In addition, the Claims Specialist (CS) and only the CS, may include a recommendation based on their perception of the individual.

  • The case is submitted to the Subsidy Appeal Unit (SAU) for the good cause determination and release of appropriate notices.

Subsidy Appeal Unit:

  • The Subsidy Determination Reviewer (SDR) will complete the appropriate MAPS screens for subsidy continuation and good cause determination as well as the subsidy end date, if appropriate.

  • The MAPS Subsidy Continuation (DWSC) screen is removed from the MAPS application and the Determination Data History section of the MAPS Query will display, “Automatic Subsidy Continuation.”

NOTE: Subsidy continuation during an appeal is not considered an overpayment in the event the appeal decision is unfavorable.

6. Allegations of Higher Income Related Work Expenses (IRWE) or Blind Work Expenses (BWE)

See HI 03020.030D. if an eligible individual indicates they have a higher IRWE or BWE. Record the documentation in MAPS per HI 03010.040.

C. Process

1. Requesting an Appeal

The individual or their personal representative (as defined in 42 CFR 423.772 and HI 03010.010B.) may request an appeal by calling the national toll-free 800 number or by calling, writing, or visiting any Social Security office. They can also obtain a copy of the SSA-1021 (Appeal of Determination for Help with Medicare Prescription Drug Plan Costs) from the internet. The mailing address on the form will be the address for WBDOC. There is no signature requirement and no signature proxy. See HI 03040.100 for establishing an appeal in MAPS.

2. Appeal Method

The appeal method is a hearing by telephone unless the individual waives the hearing by telephone and agrees to a hearing by case review.

The 800 number agents, FO employees, and WBDOC establish the appeal by completing the Appeal Application screens in MAPS.

Once established, the case is submitted to the SAU in the Office of Earnings and International Operations (OEIO). The SDR in the SAU makes all appeal decisions.

NOTE: 

This special unit was established to process subsidy appeals.

Once the case is reviewed and decided by the SDR, the SDR will trigger the appeal decision notices through the Document Generation System (DGS).

The individual may also receive a notice from the subsidy determination process if there is a change in the subsidy eligibility.

See HI 03040.300C. for more information on appeal disposition notices.

If the caller has additional information to support the appeal, direct the caller to mail it to the SAU at the following address:

Social Security Administration

Medicare - Subsidy Appeals Unit

P.O. Box 17720

Baltimore, MD 21235-7720

a. Case Review

The individual can request an appeal by case review. The appeal will be:

  • Established in MAPS; and

  • Submitted to the SAU.

  • The SAU to whom the case is assigned will send an acknowledgment notice using the DGS.

  • If there is a new issue to be decided, the acknowledgment notice will inform the individual about the new issue and provide them with the opportunity to provide additional information. The SDR will then make a decision based on the information available.

b. Telephone Hearing

If an individual requests an appeal by telephone, an appointment will be scheduled by the SAU giving the individual at least 20 days to prepare for the appeal.

When the SAU sends the appointment notice, they will accommodate the times requested by the individual unless for some very good reason it is not possible.

If the individual waives the 20-day period, a telephone hearing will be scheduled as soon as possible.

The SAU records the hearing to allow preparation of a certified transcript, if one is determined necessary.

The appeal will be established in MAPS and submitted to the SAU.

The SDR will conduct the telephone hearing, and decide the case.

The individual can request a delay (one delay may be approved; up to 2 delays if the individual has good cause). Examples of good cause reasons include, but are not limited to:

  • Individual attempted to obtain information but needs additional time;

  • Individual’s representative has a prior commitment to be in court or at another administrative hearing on the date the hearing is scheduled;

  • Individual offering assistance would be unavailable to participate in the scheduled hearing;

  • Individual is unrepresented, and is unable to respond to the notice of hearing because of physical, mental, educational, or linguistic limitations (including any lack of facility with the English language); or

  • Individual did not receive notice of the hearing appointment;

  • Individual was hospitalized at time of appointment.

  • If the individual did not request a delay but is not present at time of the scheduled hearing, the SDR will wait 1-2 days before making a decision based on the information available. If the individual wishes to proceed with a hearing, the SDR will reschedule if the individual had good cause for missing the scheduled hearing. For example, the individual was suddenly hospitalized at the time of the scheduled hearing.

3. New Issue

The appeal is a review of all facets of the determination not just those that the applicant found unsatisfactory. A new issue is an issue that was not considered in the initial determination. Where the SDR is deciding a new issue, the individual will be notified of the new issue being decided prior to the review. The SDR will add the new issue to the acknowledgment or appointment notice and when making their decision, the notice will include appeal rights.

4. When Both Members of Couple Are Eligible for Subsidy

Determine if the individual requesting an appeal is married and has a living-with spouse and whether the living-with spouse is also requesting an appeal.

If both spouses are requesting an appeal, MAPS establishes two appeals and both will receive a notice of decision.

If only one spouse appeals, but the other spouse’s eligibility for a subsidy is adversely affected by our decision upon review, the adversely-affected spouse will be sent a notice by the SDR prior to issuance of the decision, and given an opportunity to provide additional information.

Allow 15 days from the date notice is received for the spouse to respond.

If the spouse contacts the FO or calls the national 800 number requesting more information, follow HI 03040.100B.3. If the spouse asks where to submit additional information, provide the SAU address in HI 03040.001C.2. in this section.

If no response is received, process the request of the spouse who filed the appeal.

5. Waive Telephone Hearing (Case Review)

If the individual chooses not to have a hearing by telephone, it will be established in MAPS. The decision will then be made by a case review, i.e., the decision will be based on the information in the file and any additional information provided by the individual.

6. Timeframes and Good Cause

Administrative review must be requested within 60 days after the date the individual receives notice of the initial determination.

The date that the individual receives the notice is presumed to be 5 days after the date on the notice unless the individual can show us that they did not receive it within the 5 days.

If the timeframe is missed, the individual may ask us for more time to request a review.

The request for an extension must explain why it was not filed within the stated time period and the reason entered on the Good Cause for Late Filing screen in MAPS.

The SDR will determine whether the individual has good cause for missing the timeframe.

NOTE: 

The guidelines for determining good cause are the same good cause guidelines found in GN 03101.020.

7. Notice of Decision

The SDR makes the decision and is responsible for sending the appropriate notice. See HI 03040.300C. for more detail on the decisional notices. In some situations, a second notice will be sent by the subsidy determination system.

D. References

HI 03040.100 Appeal Establishment

CITATIONS:

A. Policy

When an individual disagrees with an initial determination, we will establish an appeal in the Medicare Application Processing System (MAPS).

However, we may not take an appeal on our own motion, i.e., establish an appeal without any indication from the individual that they disagree with the initial determination.

See HI 03050.045. for the policy on fixing errors.

B. Procedure

1. Establishing the Appeal

The Appeal Application screens in MAPS, or form SSA-1021 (Appeal of Determination for Help with Medicare Prescription Drug Plan Costs) are used to obtain the following information:

  • Applicant's Name and Social Security Number (SSN)

  • Medicare Number (this number is printed on your Medicare card)

  • Spouse's Name (if spouse lives at same address as applicant) and SSN

  • Spouse's Medicare Number (this number is printed on your spouse's Medicare card)

  • The reason for the disagreement

  • Whether or not the individual will be submitting additional information

  • Whether the individual prefers a case review or a telephone hearing

  • Whether the individual wants a telephone hearing sooner if scheduling permits (at least 20 days is provided between date of request and date hearing is scheduled). Make it clear the Subsidy Appeals Unit (SAU) will schedule the appointment and send the appointment notice.

  • Whether an interpreter is needed and whether the individual is hearing impaired

  • Whether or not a conference call is needed if the hearing is to be via telephone (i.e. whether the individual will be represented, or will include another party in the hearing)

  • Claimant’s statement explaining good cause for late filing of appeal

NOTE: 

When multiple applications are in MAPS, due to a systems limitation, an appeal can only be established on the most recent application.

Establish the appeal on the current application.

Include a Report of Contact (DWRC) screen stating: the appeal is established on the current application due to a systems limitation; show the date of the application being appealed; and state that this is the date that should be used for the appeal determination.

a. Applicant Requests an Appeal via 800# or in Field Office (FO)

The SSA employee will:

  • Conduct a brief interview with the individual or the person acting on the individual's behalf. Make it clear to the individual that the SAU will schedule the appointment (if hearing by telephone is requested) and send the individual an appointment notice.

  • Determine whether the individual is requesting an appeal, requesting an explanation of a determination, reporting a subsidy changing event (marriage, divorce, death of spouse, separation, annulment, separated spouses living together again, or spouse newly enrolls for subsidy) or reporting another event that may change the subsidy determination. There is more information on subsidy changing events and other reporting events in HI 03050.025. Also, in HI 03050.025C., there is a chart for handling calls within and outside the appeal period.

  • If a request for appeal is mailed to the FO, review the appeal information to make sure it is complete and readable. Contact the individual to obtain clarification on any items before entering information on the Appeal screens in MAPS. Make two attempts to phone the individual before submitting the appeal to the SAU. Document attempts on the DWRC screen in MAPS (date, time, and phone number).

  • Establish the appeal by completing the Appeal Application screens in MAPS. See MS 03207.001.

  • Document the MAPS DWRC screen with additional information. Accept any reasonable allegation (e.g., lower income due to loss of job). Destroy paper copies of additional documentation and return original documents to the individual.

  • Document the reason for late filing on the Good Cause for Late Filing screen in MAPS. Accept any reason the individual gives.

  • If a recent change of address or phone number is indicated, enter the new address/phone number on the appeal screens in MAPS. This entry will not update the MBR/SSID records, so you must also follow change of address instructions in HI 03050.020E.

  • For applicants with foreign addresses, record on the MAPS APIS screen (Section titled: "Please explain why you disagree with our decision") the following information: the applicant’s mailing address and telephone number, and the field office code of the office establishing the appeal.

  • Do not ask the caller for two preferences for the date and timeframe (morning or afternoon) for the hearing appointment and do not enter any preferences to MAPS. Make it clear to the caller that the SAU will schedule the appointment and send an appointment notice.

  • Submit the request to the SAU.

  • For telephone hearing, the SDR schedules the appointment (not the 800 # agent or the FO) and sends the appointment notice. For case review, the SDR sends the acknowledgment notice.

b. Applicant Requests an Appeal via Mail to WBDOC

The SSA employee will:

  • Establish the appeal in MAPS.

  • Attempt two phone contacts with the individual to obtain clarification on any items that are incomplete or unreadable or to determine the reason for late filing, if applicable.

  • Document the DWRC screen or the Good Cause for Late Filing screen in MAPS. Accept any explanation the individual gives.

  • Fax any additional or supporting information that accompanied the appeal request to the SAU. At the end of each day, batch additional/supporting information and send to the SAU. Determine SAU by following instructions in HI 03040.001C. Include the SSN on all supporting information. Document on DWRC, additional information faxed to (fill-in jurisdictional SAU).

  • If a recent change of address is indicated, enter the new address on the appeal screens in MAPS.

    IMPORTANT: This entry will not update the MBR or SSID, so you must follow change of address instructions in HI 03050.020E.

  • For applicants with foreign addresses, record on the MAPS APIS screen the following information: the applicant’s mailing address and telephone number. This information should be entered in the section titled “Please explain why you disagree with our decision.”

  • Submit the request to the SAU. Once the appeal request has been established, the paper form may be discarded. Ensure all information has been input in MAPS before destroying the appeal form.

  • For telephone hearing, the SDR schedules the appointment and sends the appointment notice. For case review, the SDR sends the acknowledgment notice.

2. Handling a Subsequent Application

a. First Application Is Denied and Subsequent Application Is Received Within 60-Day Timeframe

If the initial application was denied and the subsequent application is received within 60 days of initial denial notice, the Claims Specialist (CS) will compare the applications. If the subsequent application represents a change, establish an appeal. See HI 03010.010F. for procedures on subsequent applications.

b. First Application Is a Subsidy Award and Subsequent Application Is Received Within 60-Day Timeframe

If the initial application resulted in a subsidy and the subsequent application is received within 60 days of the initial application, then the two applications will be compared to determine whether an appeal will be taken. See HI 03010.010F. for instructions on subsequent applications.

NOTE: Starting January 1, 2024, the Inflation Reduction Act (IRA) provides all Extra Help beneficiaries full subsidy. A partial subsidy determination can only be made on an Extra Help case that has a coverage start date before January 1, 2024.

c. Processing Subsequent Applications with Subsidy Changing Event Indicator or Outside Appeal Period

Follow the instructions in HI 03010.010F.2.

d. Canceling Subsequent Application While Appeal Pending on First Application

The subsequent application will be transferred to the jurisdictional SAU when an appeal is pending on the first application. The SAU will use the information from the subsequent application in their decision, list the subsequent application as evidence, and address the subsequent application in their notice. The SAU will cancel the subsequent application in MAPS.

3. Referrals to the Subsidy Appeals Unit (SAU)

a. Inquiries from individuals

You may receive inquiries from individuals who wish to contact the SAU directly (e.g., to confirm that they received the additional information they sent to support an appeal or to reschedule appointments). Handle these requests as follows.

  • Provide the individual with the toll-free number for the SAU: 866-865-5311.

b. Requests for the Mailing SAU address

You may also receive requests for the mailing address of the SAU (e.g., the caller has an appeal pending and would like to submit additional information to support the appeal). Handle these requests as follows.

  • Provide the caller with the mailing address for the SAU.

    Social Security Administration

    Medicare - Subsidy Appeals Unit
    P.O. Box 17720

    Baltimore, MD 21235-7720

HI 03040.200 Appeal Processing

CITATIONS:

20 CFR 418.3605 - 418.3680

A. Policy

1. Opportunity to Review File

The subsidy determination and appeal file are electronic. The individual, upon request, is entitled to a copy of all the information in their file. If an individual asks to review their file, refer the individual to the appropriate Subsidy Appeals Unit (SAU). See HI 03040.100B.3. The SAU will contact the local Field Office (FO) to make the arrangements and recontact the individual to let them know when it is possible.

The file will include information shown in Medicare Application Processing System (MAPS), a copy of the initial determination, and information in records available to SSA, etc. Follow disclosure policy in GN 03300.000.

2. Time of Hearing and Good Cause

Individual/representatives and witnesses should be available at least 15 minutes before the time scheduled for the hearing. The times will be shown on the Notice of Hearing Appointment. Agree to the first request for postponement for any reason and to additional requests if there is good cause. If the individual is not available at the time of the phone hearing or did not request a postponement, the Subsidy Determination Reviewer (SDR) will wait 2 days to see if the individual contacts us before conducting a case review based on the information in the file plus any additional information provided, and will send the notice of decision.

For examples of some reasons for missing the scheduled hearing, see HI 03040.001C.2.b.

3. One Hearing for Members of Couple

If an individual and their living-with spouse both file an appeal, each will receive a notice of decision. At the time the SDR schedules the appeal, the SDR may ask whether the couple agrees to one combined phone hearing in which case one appointment notice may be sent. If each wishes to have their own hearing, two appointment notices are required.

4. Additional Information Documentation

Additional information is documented on the Report of Contact (DWRC) screen in MAPS. Photocopies are acceptable and should be destroyed after the information is documented in MAPS. Original documents are returned to the individual. Destroy facsimiles.

If additional information is received without a written request for appeal, it will be treated as an implied request for appeal. Contact the individual to get information for completing the Appeal Application Screens in MAPS. If the individual cannot be reached, complete as much as necessary of the Appeal Application Screens to submit to the SAU.

5. Telephone Hearing Continuation

If a SDR fails to cover all of the issues or obtain all of the information at the time of the hearing and another call to the individual is necessary, record any additional calls. A continued hearing would be one in which the first hearing was postponed or delayed for some reason, e.g., a power outage cut the call short or an emergency occurred during the hearing so that it had to be postponed. All telephone hearings including continued hearings will be recorded in case there needs to be a transcript made at a later date. Document the reasons for the additional calls and continued hearing on the DWRC screen in MAPS.

6. Subpoena Witnesses

When determined to be reasonably necessary for the full presentation of a case, a subpoena may be issued to compel the production of certain evidence or testimony. A subpoena is not necessary for those witnesses who wish to participate in the hearing. See SI 04020.050 for information on use of a subpoena.

7. Dismissal

a. Pre-Decisional Determination

Taking an appeal on a pre-decisional determination is inappropriate and cannot be entered into MAPS. The pre-decisional is not an initial determination and the notice does not contain appeal rights.

  • When an individual contacts the 800 number or the field office as a result of the pre-decisional notice, make all necessary changes to the initial application and submit to subsidy determination.

  • If an individual submits a paper SSA-1021 to the field office or Wilkes-Barre Direct Operations Center (WBDOC) based on a pre-decisional notice, the employee will verify the additional or updated information; make the changes in MAPS, and complete case processing by submitting the updated information to subsidy determination. Immediately fax the paper SSA-1021 to the Woodlawn, Maryland SAU (fax no. 410-594-2066) to process the dismissal.

  • Batch the paper SSA-1021s at the end of each day and mail the batch to: Medicare Subsidy Appeals Unit, P.O. Box 17720-7720, Baltimore, MD 21235. The Woodlawn Subsidy Appeals Unit will send the individual a dismissal notice. Pre-decisional issues policy is captured in subchapter HI 03035.000.

  • The SAU will wait until the notice of denial/award is released. Contact the individual to determine whether they wish to continue with the appeal and handle accordingly.

b. Dismissal of Appeal on Initial Determination

Only the SAU may dismiss an appeal. It is important that care is taken to ensure that the dismissal is appropriate. Once an appeal is dismissed, the individual loses their right to appeal.

We will mail a written notice of the dismissal to the individual at their last known address. The notice will include the reason for the dismissal and the effect of the dismissal on the individual’s subsidy if the individual is receiving a subsidy. For example, the individual was receiving a subsidy and receives a notice that it is being terminated as a result of a subsidy changing event. The individual appeals the termination and the appeal is dismissed for lack of good cause for late filing. The notice will explain that the individual's subsidy will terminate.

Some dismissal reasons include:

  • Issue appealed is not an initial determination

  • Individual did not file an application for a subsidy

  • Individual requesting appeal is not proper party. Before dismissing the appeal, attempt phone contact with the applicant to determine if they want to appeal.

  • Individual failed to request administrative review timely and did not have good cause for missing the deadline for requesting review.

  • Individual dies while the appeal is pending and was not enrolled in a prescription drug plan (PDP) or Medicare Advantage with prescription drug coverage (MA-PD).

    NOTE: 

    SSA will not dismiss the request for appeal if we find that the individual is eligible for a subsidy or has been paying a Part D premium whether through Social Security benefit deduction or out-of-pocket. The SDR will issue a decision and send to last known address.

  • An appeal was taken in error.

    •  

      The dismissal is binding unless it is vacated by a SDR supervisor. A SDR supervisor may vacate any dismissal of a request for appeal if, within 60 days after the date the individual receives the dismissal notice, they request that the dismissal be vacated and shows good cause why the request should not be dismissed.

    •  

      If an individual contacts the FO or calls the national 800 number to request vacating the dismissal, refer the caller to the SAU. See HI 03040.100B.3.

8. Disqualification of Subsidy Determination Reviewer (SDR)

The SDR conducting the hearing will not conduct the telephone hearing if they are prejudiced or partial with respect to any party or has any interest in the matter pending for decision. The SDR supervisor will decide whether to proceed with the telephone hearing or to appoint another person to conduct the hearing.

B. Process - Subsidy Appeal Unit Overview

Case Review

Telephone Hearing

  1. 1. 

    Case Review

    • SDR conducts case review

    • Inputs eligibility data (income, resource, etc) in MAPS

  2. 2. 

    Post Review Activities

    • SDR prepares and sends the Notice of Decision,

    • FAX COA to FO for necessary action

    • SDR generates the list of exhibits

    • SDR inputs the decision

  1. 1. 

    SDR schedules/reschedules appointment

  2. 2. 

    SDR sends Appointment Notice

  3. 3. 

    Pre-Hearing Review

    SDR reviews file

  4. 4. 

    Hearing

    • SDR conducts phone hearing, documents names of those participating in hearing, records and documents record of hearing using identification information (appellant’s name, SSN, etc)

    • Inputs eligibility data (income, resources, etc) in MAPS

  5. 5. 

    Post Hearing Activities

    • SDR prepares and sends the Notice of Decision

    • FAX COA to FO for necessary action

    • SDR generates the list of exhibits

    • SDR inputs the decision

The 800 number agent, FO, and WBDOC is responsible for inputting the correct appeal information in MAPS and submitting the request along with any related information to the SAU.

The SDR is responsible for processing the appeal including making the good cause determinations, sending an appropriate notice, and correcting any errors.

The SDR will complete processing as expeditiously as possible.


HI 03040 TN 7 - Appeal of Medicare Part D Subsidy Determination - 1/01/2024