Identification Number:
HI 03040 TN 8
Intended Audience:See Transmittal Sheet
Originating Office:ORDP OISP
Title:Appeal of Medicare Part D Subsidy Determination
Type:POMS Full Transmittals
Program:All Programs
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. 8, 01/23/2024

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

 

Summary of Changes

HI 03040.400 Court Remand Process

Subsection A: Changed language referencing Management Analyst to Subsidy Appeals Unit.

Subsection B: Added language about IRA change and made minor language updates to improve clarity.

Subsection C: Added to include POMS references used throughout procedure.

Revised this section as part of the Inclusive Language Initiative.

 

HI 03040.400 Court Remand Process

A. Policy

The Office of General Counsel (OGC) will act as liaison between the court and the Subsidy Appeal Unit (SAU). OGC will forward the court order to the SAU for effectuation and/or further development. The SAU is responsible for certifying the case for the court. Certification includes ensuring all relevant documents are in place and properly assembled. The SAU representative will use the following in their certification:

 

“The undersigned, as Subsidy Appeal Unit, Social Security Administration, hereby certifies that the documents annexed hereto constitute a full and accurate transcript of the entire record of proceedings relating to the case.”

 

The certification is then signed by the SAU representative.

 

If the court does not retain jurisdiction, after the administrative proceedings on remand have been completed, no further action is required with the court. The notice(s) issued is the final decision of the Commissioner.

 

If the court retains jurisdiction, after the administrative proceedings on remand have been completed, SSA must file a copy of the new final decision with the court.

 

We will look to the court order and OGC to provide guidance as to whether the court retains jurisdiction.

If the court retains jurisdiction and SSA makes a new decision, SSA must file a copy of the new SSA decision with the court and a new transcript may need to be certified.

B. Procedure

When OGC transfers the court remand to the SAU, the Subsidy Determination Reviewer (SDR) will review the case based on instructions by the court and OGC. The SDR will undertake further development which may include a new hearing or case review and changes to eligibility criteria in Medicare Application Processing System (MAPS). Any notices that are issued will come from Document Generation System (DGS) and the determination process, as appropriate. A hearing is required unless waived by the claimant, see HI 03040.001C.2., or unless the SDR can make a fully favorable decision, i.e., full subsidy, without a hearing.

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.

The court will either retain jurisdiction or return jurisdiction to SSA.

If the court retains jurisdiction, the DGS notice will explain in the appeal paragraph that the individual has 10 days to let us know if they disagree with the decision before we will file a certified copy of the administrative record with the court.

Where the court does not retain jurisdiction, the DGS notice will explain that the court order returning the case back to the Commissioner ends the court’s review. If the individual disagrees with the notice of decision issued by the SAU upon remand, the individual must file a new civil action.

There is a timeframe for continuing the appeal process. Individuals may file an action in Federal district court within 60 days after the date the individual receives notice of the decision. If the individual requests an extension of time, the SDR will determine whether the individual has good cause, document the reason(s), and send appropriate DGS notice. For more information about reviewing and processing good cause requests, see HI 03040.001 and GN 03101.020.

C. References

  • GN 03101.020 Good Cause for Extending the Time Limit to File an Appeal

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


HI 03040 TN 8 - Appeal of Medicare Part D Subsidy Determination - 1/01/2024