ALSC04
|
CAPTION
|
If You Disagree With The Decision
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|
ALSC30
|
CAPTION
|
Appeal In 10 Days To Keep Getting The Same Help
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|
ALS127
|
RULES FOR APPEAL
|
-
•
We will not change the help you get if you appeal in 10 days.
-
•
The 10 days start the day you get this letter.
-
•
The help you get will [1] only if your appeal is denied.
|
Fill-ins:
[1] "be reduced"/"stop"
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ALS128
|
PRE-DECISIONAL – INSTRUCTION
FOR SUBMISSION OF NEW INFO
|
If you disagree with the information in our records, you must contact us within 10
days from the date you receive this notice. You may call us toll-free at 1-800-772-1213
or call or visit the local field office shown below. If you do not contact us within
10 days, your claim will be denied.
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|
|
ALS129
|
EXPLANATION OF APPEAL RIGHTS
|
If you disagree with the decision, you have the right to appeal. We will provide you
with a hearing by telephone or a case review. We will look at any new information
you have. The person who will conduct the hearing or case review had no prior involvement
in the first decision. We will review those parts of the decision which you believe
are wrong and will look at any new facts you have. We may also review those parts
which you believe are correct and may make them unfavorable or less favorable to you.
If you want this appeal, either by a hearing or a case review, you may request it
by calling toll-free 1-800-772-1213.
-
•
You have 60 days to ask for an appeal.
-
•
The 60 days start the day after you get this letter. We assume you got this letter
5 days after the date on it unless you show us that you did not get it within the
5-day period.
-
•
You must have a good reason for waiting more than 60 days.
-
•
You can call to request an appeal. You can also obtain a copy of the form SSA-1021,
“Request for Appeal of Determination for Help with Medicare Prescription Drug Plan
Costs” from www.socialsecurity.gov. Contact us if you need help.
|
|
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CAPC22
|
CAPTION
|
If you Disagree With Our Records |
|
|
ENC008
|
ENCLOSURE REMARK
|
Enclosure(s)
|
|
|
MPDC01
|
CAPTION
|
Information About This Help With Your Prescription Drug Plan Costs
|
|
|
MPDC02
|
CAPTION
|
Why You Are Not Eligible For Help With Your Prescription Drug Plan Costs
|
|
|
MPDC03
|
CAPTION
|
Why You May Not Be Eligible For Help With Your Prescription Drug Plan Costs
|
|
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MPDC04
|
CAPTION
|
Why Your Help Will Terminate
|
|
|
MPDC05
|
CAPTION
|
Your Help Will Terminate
|
|
|
MPDC06
|
CAPTION
|
Information Used To Determine Your Eligibility
|
|
|
MPDC07
|
CAPTION
|
Information Used In Making The Decision
|
|
|
MPDC08
|
CAPTION
|
What To Do If Your Situation Changes
|
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|
MPDC09
|
CAPTION
|
Your Help Will Change
|
|
|
MPDC10
|
CAPTION
|
If You Are Not Correcting Any Information
|
|
|
MPDC11
|
CAPTION
|
How To Sign Up For A Medicare Prescription Drug Plan
|
|
|
MPDC12
|
CAPTION
|
Information About Food Stamps
|
|
|
MPDC13
|
CAPTION
|
Information About Medicare Savings Programs
|
|
|
MPDC14
|
CAPTION
|
How We Counted Your [1] To Determine Your Subsidy
Fill-ins:
[1] "Resources"/"Income"
|
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|
MPDC15
|
CAPTION
|
How We Counted Your And Your Spouse's [1] To Determine Your Subsidy
Fill-ins:
[1] "Resources"/"Income"
|
|
|
MPDC16
|
CAPTION
|
How You May Be Able To Receive SSI
|
|
|
MPD001
|
STATEMENT FOR NOTICE OF RECEIPT
OF APPLICATION
|
This is a Receipt for Your Application for Help With Medicare Prescription Drug Plan
Costs
|
|
|
MPD074
|
RECEIPT OF APPLICATION (SSA-1020SC)
FOR SUBSIDY CHANGING EVENTS
|
We received your updated Application for Help with Medicare Prescription Drug Plan
Costs and will process it as quickly as possible. We will contact you if we need more
information. If there will be any change in your subsidy, you will receive another
notice in December 2005.
|
|
|
MPD081
|
DENIAL - FAILURE TO COOPERATE
|
We asked you to provide evidence concerning your Application for Help with Medicare
Prescription Drug Plan Costs. You did not give us the information we asked for. Therefore,
we must make our determination based on the information we have. Based on our records,
we have determined that you are not eligible to receive extra help with Medicare prescription
drug plan costs.
|
|
|
MPD090
|
AWARDED FULL OR PARTIAL SUBSIDY – INTRODUCTORY
|
You are eligible for extra help with your Medicare prescription drug plan costs. To
take advantage of this benefit, you must enroll in a Medicare approved prescription
drug plan or Medicare Advantage plan with prescription drug coverage, if you are not
already enrolled in one. If you do not choose a Medicare prescriptions drug plan Medicare
will choose one for you to be sure you get this benefit. You will receive more information
from Medicare.
The rest of this letter explains the extra help with the prescription drug plan costs,
the information used to determine your eligibility, how to sign up for a Medicare
prescription drug plan, what to do if your situation changes, and your appeal rights.
|
|
|
MPD091
|
EXPLANATION OF BASIC ELIGIBILITY
|
You are eligible for [1] help to pay your Medicare prescription drug premium, also
known as subsidy, because your income is below the limits established by the law.
Fill-ins:
[1] "full/"partial"
|
|
|
MPD092
|
AWARDS - DISTINGUISHES RESOURCE
LEVELS
|
Because your resources are [1], you are also eligible for lower prescription drug
co-payments and annual deductibles.
Fill-ins:
[1] "less than or equal to $6000"/"less than or equal to $9000"
|
|
|
MPD093
|
RANGE OF RESOURCES
|
Your resources we count are [1]. The enclosed worksheet shows you how we counted your
resources.
Fill-ins:
[1] "less than or equal to $6,000"/"less than or equal to $9,000"/"more than $6,000
and less than or equal to $10,000"/"more than $9,000 and less than or equal to $20,000"/"more
than $10,000"/"more than $20,000"
|
|
|
MPD094
|
APPLICANT HAS NO RESOURCES
|
[1] have no countable resources.
Fill-ins:
[1] "You"/"You and your spouse"
|
|
|
MPD095
|
INSUFFICIENT INCOME/RESOURCE INFO
|
We did not make a decision on your [1], because you have not provided enough information
about your [2].
Fill-ins:
[1] "income"/"resources"
[2] "income"/"resources"
|
|
|
MPD096
|
FAMILY SIZE USED IN DETERMINATION
|
You have [1] [2] in your household. When we determine the size of your household,
we count you, your spouse who lives with you, and any relative who lives with you
and receives one-half support from you or your spouse.
Fill-ins:
[1] number of persons in household
[2] "person"/"persons"
|
|
|
MPD097
|
EXPLANATION OF SUBSIDY CHANGING
EVENTS
|
Certain changes in your situation may affect the amount of extra help you can receive
to pay for your prescription drug plan costs. You can contact Social Security to tell
us if any of the following changes happens:
-
-
•
you and your spouse who lives with you divorce;
-
•
your spouse who lives with you dies;
-
•
you and your spouse separate;
-
•
you and your spouse have your marriage annulled; or
-
•
you and your separated spouse begin living together again.
|
|
|
MPD098
|
FILE A NEW APPLICATION FOR SUBSIDY
|
If at any time in the future you think you qualify for this extra help, also known
as a subsidy, please contact us immediately about filing a new application.
|
|
|
MPD099
|
DENIAL - APPLICANT NOT LIVING IN
U.S.
|
You cannot receive extra help with Medicare prescription drug plan costs, because
you do not live in one of the Fifty States or Washington, District of Columbia.
|
|
|
MPD100
|
PRE-DECISIONAL - APPLICANT NOT
LIVING IN U.S.
|
You may not receive extra help with Medicare prescription drug plan costs, because
you do not live in one of the Fifty States or Washington, District of Columbia.
|
|
|
MPD101
|
DENIAL OR PRE-DECISIONAL - NOT
ENTITLED TO MEDICARE PART A OR ENROLLED IN PART B (OUTSIDE ENROLLMENT PERIOD)
|
You must be entitled to Medicare Part A (Hospital Insurance) or enrolled in Medicare
Part B (Medical Insurance) to receive extra help with Medicare prescription drug plan
costs.
|
|
|
MPD102
|
DENIAL - OUTSIDE PART D ENROLLMENT
PERIOD
|
You cannot receive extra help with Medicare prescription drug plan costs, because
your application was filed too late. However, you may apply for this help again during
the next general enrollment period. A general enrollment period takes place in January,
February, and March of each year.
|
|
|
MPD103
|
DENIAL - EXCESS INCOME, RESOURCES
BELOW LIMIT
|
Since your income is over the limit, we did not consider your real estate in making
this decision. If you appeal this decision, we will need more information about the
value of your real estate.
|
|
|
MPD104
|
NOTICE OF CHANGE OR PLANNED ACTION
- INTRODUCTORY
|
We are changing the amount of the extra help you get with Medicare prescription drug
plan costs. The rest of this notice explains how we figured the change, when it will
change, what information was used to make this decision, what to do if your situation
changes, and your appeal rights.
|
|
|
MPD105
|
PRE-DECISIONAL NOTICE – INTRODUCTORY
|
A review of our records shows you may not be eligible for extra help with Medicare
prescription drug plan costs.
The rest of this letter explains why we believe you may not be eligible, the information
we plan to use to determine your eligibility, and what you need to do if the information
in our records is incorrect.
|
|
|
MPD106
|
SUBSIDY DENIAL – INTRODUCTORY
|
We have determined that you are not eligible for extra help with Medicare prescription
drug plan costs. This determination is based on the letter we previously sent you
and any additional information you submitted.
The rest of this notice explains how we determined that you are not eligible, the
information we used to make this decision, how to sign up for a Medicare prescription
drug plan, what to do if your situation changes, and your appeal rights.
|
|
|
MPD107
|
NOTICE OF SUBSIDY TERMINATION DATE
|
You will no longer be able to get extra help with your Medicare prescription drug
plan costs effective [1].
Fill-ins:
[1] month and year of termination
|
|
|
MPD108
|
SUBSIDY TERMINATION – INTRODUCTORY
|
We can no longer give you extra help with Medicare prescription drug plan costs. The
rest of this notice explains how we figured the change, when it will change, what
information was used to make this decision, what to do if your situation changes and
your appeal rights
|
|
|
MPD109
|
REASON FOR SUBSIDY TERMINATION
|
Because [1], you are not eligible for extra help with your Medicare prescription drug
plan costs effective [2].
Fill-ins:
[1] "of your resources"/"of your income"/"of your resources and income"/"you are not
living in one of the Fifty States or Washington, District of Columbia"/"you are not
entitled to Medicare Part A (Hospital Insurance) or enrolled in Medicare Part B (Health
Insurance)"/" you did not return the requested form in 90 days"
[2] Month and year of termination
|
|
|
MPD110
|
PRE-DECISIONAL DENIAL FOR RESOURCE/
INCOME
|
You may not be eligible for a subsidy to help pay your Medicare prescription drug
plan costs because [1] above the limit established by law.
Fill-ins:
[1] "your resources are"/"your income is"/"both your resources and income are"
|
|
|
MPD111
|
DENIAL - BASED ON EXCESS RESOURCES
AND/ OR INCOME
|
You are not eligible for extra help to pay your Medicare prescription drug plan costs,
also known as subsidy, because [1] above the limit established by law.
Fill-ins:
[1] "your resources are"/"your income is"/"both your resources and income are"
|
|
|
MPD112
|
INCOME VS PERCENTAGE OF POVERTY
LEVEL
|
Your income we count is [1] the Federal Poverty Level. The enclosed worksheet shows
you how we counted your income.
Fill-ins:
[1] "less than 135% of"/"between 135% and 139% of "/"between 140% and 144% of"/"between
145% and 149% of"/"150% or more of"
|
|
|
MPD113
|
APPLICANT HAS NO INCOME
|
[1] have no income.
Fill-ins:
[1] "You"/"You and your spouse"
|
|
|
MPD114
|
NON-AWARDS - HOW TO ENROLL IN 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. [1] For more information about the prescription
drug plans available in your area, go to www.medicare.gov 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.
Fill-ins:
[1] "you can enroll beginning November 15, 2005."/Null
|
|
|
MPD115
|
MEDICARE SAVINGS PROGRAM REFERRALS
|
You may be able to get more help with your Medicare health care costs through programs
run by your State. The additional help from these Medicare Savings
Programs can be worth more than $900 a year. To get this help, please call your State’s medical
assistance (Medicaid) office or your social service office and ask about the Medicare
Savings Programs. You can get the local phone number for these offices by calling
Medicare toll-free at 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.
|
|
|
MPD116
|
PRE-DECISIONAL NOTICE - TIME LIMIT
FOR RECEIPT OF NEW INFORMATION
|
If the information in our records is correct, you do not need to do anything. If you
do not reply within 10 days, we will send you a formal notice denying your Application
for Help With Medicare Prescription Drug Plan Costs.
|
|
|
MPD117
|
EXPLANATION OF MARITAL STATUS
|
When you are married and live with your spouse, we count the resources and income
for both of you when we determine your eligibility for this extra help.
|
|
|
MPD118
|
ELIGIBILITY FOR FOOD STAMPS
|
You may also be eligible for food stamp benefits. These benefits can help you stretch
your food dollars to buy nutritious food for better health. For more information,
contact your local social services office or call the Food Stamp Program information
line toll-free at 1-800-221-5689
|
|
|
MPD120
|
INCOME WORKSHEET - WORK EXPENSES
RELATED TO BLINDNESS DEDUCTED FROM COUNTABLE INCOME
|
Because you are under age 65 and you have work expenses related to blindness, we do
not count 25% of your gross wages when we determine the amount of your income that
we count.
|
|
|
MPD121
|
INCOME WORKSHEET - WORK RELATED
EXPENSES ARE DEDUCTED FROM COUNTABLE INCOME
|
Because you are under age 65 and you have work expenses related to your disability,
we do not count 16.3% of your gross wages when we determine the amount of your income
that we count.
|
|
|
MPD122
|
INCOME/RESOURCE WORKSHEET - PROVIDES
EFFECTIVE DATE OF SUBSIDY
|
For [1] and continuing
Fill-ins:
[1] Month YYYY
|
|
|
MPD123
|
INCOME WORKSHEET - PROVIDES AMOUNT
OF APPLICANT'S SOCIAL SECURITY BENEFITS
|
Social Security $[1]
Fill-in:
[1] Yearly amount of Social Security benefit
|
|
|
MPD124
|
INCOME WORKSHEET - REPORTED AMOUNT
OF APPLICANT'S RAILROAD RETIREMENT BENEFITS
|
Railroad Retirement [2]
Fill-in:
[1] Yearly amount of Railroad Retirement benefit
|
|
|
MPD125
|
INCOME WORKSHEET - REPORTED AMOUNT
OF APPLICANT'S VETERAN'S BENEFITS
|
Veteran’s Benefits [1]
Fill-in:
[1] Yearly amount of Veteran's benefits
|
|
|
MPD126
|
INCOME WORKSHEET - REPORTED TOTAL
OF APPLICANTS OTHER PENSIONS OR ANNUITIES
|
Other Pensions or Annuities [1]
Fill-in:
[1] Yearly amount of total of all other pensions or annuities
|
|
|
MPD127
|
INCOME WORKSHEET - REPORTED IN-KIND
SUPPORT AND MAINTENANCE
|
In-Kind Support and Maintenance [1]
Fill-in:
[1] Yearly amount of In-Kind Support and Maintenance
|
|
|
MPD128
|
INCOME WORKSHEET - REPORTED AMOUNT
OF OTHER INCOME
|
Other Income [1]
Fill-in:
[1] Yearly amount of Other Income
|
|
|
MPD129
|
INCOME WORKSHEET - INDICATES AMOUNT
OF GENERAL INCOME EXCLUSION
|
(General Income Exclusion) [1]
Fill-in:
[1] Amount of General Income Exclusion
|
|
|
MPD130
|
INCOME WORKSHEET – SUBTOTAL
|
Subtotal of Your Income We Count [1]
Fill-in:
[1] Subtotal of Income
|
|
|
MPD131
|
INCOME WORKSHEET - PROVIDES THE
AMOUNT OF THE APPLICANT'S REPORTED WAGES
|
Wages [1]
Fill-in:
[1] Amount of reported wages
|
|
|
MPD132
|
INCOME WORKSHEET - PROVIDES THE
AMOUNT OF THE APPLICANT'S REPORTED SELF EMPLOYMENT INCOME
|
Net Self-Employment Earnings [1]
Fill-in:
[1] Amount of Self Employment Income reported
|
|
|
MPD133
|
INCOME WORKSHEET - PROVIDES THE
AMOUNT OF THE APPLICANT'S REPORTED NET LOST FROM SELF EMPLOYMENT
|
Net Loss from Self-Employment [1]
Fill-in:
[1] Amount of Self Employment Net Loss reported
|
|
|
MPD134
|
INCOME WORKSHEET - AMOUNT OF EARNED
INCOME EXCLUSION
|
(Earned Income Exclusion) [1]
Fill-in:
[1] Amount of Earned Income exclusion
|
|
|
MPD135
|
INCOME WORKSHEET - IMPAIRMENT RELATED
WORK EXPENSES
|
(Impairment Related Work Expenses That We Deduct) [1]
Fill-in:
[1] Amount of Impairment Related Work expense deducted
|
|
|
MPD136
|
INCOME WORKSHEET - AMOUNT NOT COUNTED
|
(By Law, We Don’t Count Half Of This Amount)[1]
Fill-in:
[1] Amount of income not counted
|
|
|
MPD137
|
INCOME WORKSHEET - WORK EXPENSES
FOR BLIND APPLICANT
|
(Work Expenses of the Blind That We Deduct) [1]
Fill-in:
[1] Amount of work expenses deducted for blind applicant
|
|
|
MPD138
|
INCOME WORKSHEET - TOTAL OF WAGES/SELF
EMPLOYMENT
|
Total of Wages/Self Employment That We Count [1]
Fill-in:
[1] Total amount of wages or self employment counted
|
|
|
MPD139
|
INCOME WORKSHEET - TOTAL OF INCOME
COUNTED
|
Total Income We Count [1]
Fill-in:
[1] Total amount of income counted
|
|
|
MPD140
|
INCOME WORKSHEET - INCOME LIMIT
FOR SUBSIDY ELIGIBILITY
|
Income limit For Subsidy Eligibility [1]
Fill-in:
[1] Income limit used for determination of Subsidy
|
|
|
MPD141
|
AWARDED FULL OR PARTIAL SUBSIDY
AFTER APPEAL – INTRODUCTORY
|
You are eligible for extra help with your Medicare prescription drug plan costs, because
a favorable decision was made on your appeal. To take advantage of this benefit, you
must enroll in a Medicare approved prescription drug plan or Medicare Advantage plan
with prescription drug coverage, if you are not already enrolled in one. If you do
not choose a Medicare prescription drug plan, Medicare will choose one for you to
be sure you get this benefits. You will receive more information from Medicare.
The rest of this letter explains the extra help with the prescription drug plan costs,
the information used to determine your eligibility, how to sign up for a Medicare
prescription drug plan, and what to do if your situation changes.
|
|
|
MPD142
|
SUMMARY AND LISTING OF COUNTABLE
RESOURCES
|
[1] have the following resources:
Fill-in:
[1] "You"/"You and your spouse"
|
|
|
MPD143
|
RESOURCE WORKSHEET - TOTAL AMOUNT
OF APPLICANT’S REPORTED BANK ACCOUNTS
|
Bank Accounts [1]
Fill-in:
[1] Amount of reported bank accounts
|
|
|
MPD144
|
RESOURCE WORKSHEET - REPORTED STOCKS,
BONDS, OTHER INVESTMENTS
|
Stocks, Bonds, or Other Investments [1]
Fill-in:
[1] Amount of stocks, bonds, or other investments
|
|
|
MPD145
|
RESOURCE WORKSHEET - APPLICANT'S
TOTAL CASH
|
Cash [1]
Fill-in:
[1] Amount of reported cash
|
|
|
MPD146
|
RESOURCE WORKSHEET - APPLICANT'S
CASH VALUE OF LIFE INSURANCE
|
Cash Value of Life Insurance [1]
Fill-in:
[1] Amount of reported cash value of applicant's life insurance
|
|
|
MPD147
|
RESOURCE WORKSHEET - APPLICANTS
REAL ESTATE
|
Real Property [1]
Fill-in:
[1] Amount of real property
|
|
|
MPD148
|
RESOURCE WORKSHEET - BURIAL FUND
MONEY NOT COUNTED
|
(Burial Fund Money We Do Not Count) [1]
Fill-in:
[1] "$1500"/"$3000"
|
|
|
MPD149
|
RESOURCE WORKSHEET - AMOUNT OF
RESOURCES COUNTED
|
Your Resources That We Count [1]
Fill-in:
[1] Amount of resources counted
|
|
|
MPD150
|
RESOURCE WORKSHEET - RESOURCE LIMIT
FOR SUBSIDY ELIGIBILITY
|
Resource Limit for Subsidy Eligibility [1]
Fill-in:
[1] "10,000"/"20,000"
|
|
|
MPD151
|
RESOURCE WORKSHEET - AMOUNT OVER
RESOURCE LIMIT
|
Amount Over The Resource Limit [1]
Fill-in:
[1] Amount over resource limit
|
|
|
MPD152
|
RESOURCE WORKSHEET - EXPLANATION
OF COUNTABLE RESOURCES
|
We counted only the resources listed above. We do not count the value of your home,
your vehicles or your personal possessions.
|
|
|
MPD153
|
RESOURCE WORKSHEET - BURIAL EXPENSES
REPORTED
|
Because you have set aside money for burial expenses, we also do not count [1]
Fill-in:
[1] "$1500"/"$3000"
|
|
|
MPD160
|
NOTICE - LISTED COUNTABLE RESOURCE
|
Cash
|
|
|
MPD161
|
NOTICE - LISTED COUNTABLE RESOURCE
|
Bank accounts
|
|
|
MPD162
|
NOTICE - LISTED COUNTABLE RESOURCENOTICE
- LISTED COUNTABLE RESOURCE
|
Stocks, bonds, or other investments
|
|
|
MPD163
|
NOTICE - LISTED COUNTABLE RESOURCE
|
Cash value of life insurance
|
|
|
MPD164
|
AWARDS - DETAILED SUBSIDY ELIGIBILITY
INFO
|
You are eligible for:
-
•
[1]% subsidy to help pay your Medicare prescription drug plan premiums;
-
•
[2] prescription drug annual deductible; and
-
•
Reduced co-payment amounts when you have a prescription filled.
Fill-ins:
[1] "100"/"75"/"50"/"25"
[2] "$0.00"/"Reduced"
|
|
|
MPD165
|
EXPLANATION OF INCREASE/DECREASE
IN SUBSIDY
|
You will receive [1] help, also known as the subsidy, because of a change in your
income. Beginning [2], you are eligible for:
-
•
[3]% subsidy to help pay your Medicare prescription drug plan premiums;
-
•
[4] prescription drug annual deductible; and
-
•
Reduced co-payment amounts when you have a prescription filled.
Fill-ins:
[1] "increased"/"reduced"
[2] month and year of change
[3] "100"/"75"/"50"/"25"
[4] "$0.00"/"Reduced"
|
|
|
MPD166
|
SUMMARY AND DETAILED LIST OF COUNTABLE
INCOME
|
[1] have the following yearly income:
Fill-ins:
[1] "You"/"You and your spouse"
|
|
|
MPD167
|
NOTICE - LISTED COUNTABLE INCOME
|
Social Security benefits (before any Medicare premium deductions) of $[1]
|
|
|
MPD168
|
NOTICE - LISTED COUNTABLE INCOME
|
Railroad benefits (before any Medicare premium deductions) of $[1]
|
|
|
MPD169
|
NOTICE - LISTED COUNTABLE INCOME
|
Veterans benefits of $[1]
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MPD170
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NOTICE - LISTED COUNTABLE INCOME
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Other pensions or annuities of $[1]
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MPD171
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NOTICE - LISTED COUNTABLE INCOME
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Other income of $[1]
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|
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MPD172
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NOTICE - LISTED COUNTABLE INCOME
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Help with household expenses of $[1]
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MPD173
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NOTICE - LISTED COUNTABLE INCOME
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Wages of $[1]
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|
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MPD174
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NOTICE - LISTED COUNTABLE INCOME
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Wages for your spouse of $[1]
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|
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MPD175
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NOTICE - LISTED COUNTABLE INCOME
|
Net self-employment earnings of $[1]
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|
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MPD176
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NOTICE - LISTED COUNTABLE INCOME
|
Net self-employment earnings for your spouse of $[1]
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|
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MPD177
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NOTICE - LISTED COUNTABLE INCOME
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Net loss from self-employment of $[1]
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MPD178
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NOTICE - LISTED COUNTABLE INCOME
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Net loss from self-employment for your spouse of $[1]
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MPD179
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AWARDS - HOW TO ENROLL IN PRESCRIPTION
DRUG PLAN
|
This decision is about the help you can get paying for the costs related to your Medicare
prescription drug plan, such as help paying for the deductible, premiums and co-payments.
In order to get Medicare prescription drug coverage, you must be enrolled in a Medicare
prescription drug plan or a Medicare Advantage drug plan. [1] You will get more information
about the prescription drug plans available in your area. You can also visit www.medicare.gov or call toll-free 1-800-MEDICARE (1-800-633-4227) for more information. If you are
deaf or hard of hearing, you may call the Medicare TTY number toll-free at 1-877-486-2048.
Fill-ins:
[1] "you can enroll beginning November 15, 2005."/Null
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MPD180
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ADVISE APPLICANT OF POSSIBLE ELIGIBILITY
FOR SSI
|
You may be eligible for Supplemental Security Income (SSI) benefits. If you have not
already filed SSI application, it is important that you get in touch with Social Security
right away to file an SSI application. You may call us toll-free at 1-800-772-1213.
If you file the application more than 60 days from the date of this notice, and you
are found eligible, you may lose SSI benefits.
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MPD181
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ADVISE APPLICATION OF INELIGIBILITY
FOR SSI
|
It does not appear that you are eligible for Supplemental Security Income (SSI) benefits.
However, you may still want to file an SSI application if you have not already done
so. If you file an application, you will receive a formal decision of your eligibility.
If you do not agree with the decision, you may appeal. If you decide to file, it is
important that you get in touch with Social Security right away. You may call us toll-free
at 1-800-772-1213. If you file an application more than 60 days from the date of this
notice, you may lose SSI benefits.
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MPD182
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RECEIPT OF MEDICARE APPLICATION
FOR SUBSIDY- INTRODUCTORY
|
We received your Application for Help with Medicare Prescription Drug Plan Costs and
will process it as quickly as possible. We will contact you if we need more information.
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MPD183
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DUPLICATE APPLICATION - INTRODUCTORY
|
On [1], you submitted an Application for Help With Medicare Prescription Drug Plan
Costs. Since we already processed an earlier application for you, we are taking no
further action on this application.
The decision on the first application remains in effect for 12 months unless you have
a subsidy-changing event. A subsidy changing event is one of the following:
-
-
•
you and your spouse who lives with you divorce;
-
•
your spouse who lives with you dies;
-
•
you and your spouse separate;
-
•
you and your spouse have your marriage annulled; or
-
•
you and your separated spouse begin living together again.
If you have a subsidy-changing event, please call us toll-free at 1-800-772-1213.
Fill-ins:
[1] Month DD, YYYY
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MPD184
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DEEMED SSI RECIPIENT FILES FOR
SUBSIDY - INTRODUCTORY
|
On [1], you submitted an Application for Help with Medicare Prescription Drug Plan
Costs. Because you receive Supplemental Security Income, you are automatically eligible
for extra help with Medicare prescription drug plan costs. We do not need to process
your application.
Fill-ins:
[1] Month DD, YYYY
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MPD185
|
PRE-DECISIONAL DENIAL - FAILURE
TO COOPERATE
|
We asked you to provide evidence concerning you Application for Help with Medicare
Prescription Drug Plan Costs. You did not give us the information we asked for.
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MPD186
|
NOTICE OF CHANGE/NOTICE OF PLANNED
ACTION AFTER APPEAL - INTRODUCTORY
|
As a result of your appeal, we are changing the amount of the extra help you get with
Medicare prescription drug plan costs. The rest of this notice explains how we figured
the change, when it will change, what information was used to make this decision,
and what to do if your situation changes.
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MPD187
|
TERMINATION NOTICE AFTER APPEAL
- INTRODUCTORY
|
As a result of your appeal, we can no longer give you extra help with Medicare prescription
drug plan costs. The rest of this notice explains how we figured the change, when
it will change, what information was used to make this decision, and what to do if
your situation changes.
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MPD188
|
PRE-DECISIONAL AND DENIAL NOTICES
- RESOURCES EXCEED LIMIT
|
You told us that [1] resources are worth more than [2].
Fill-ins:
[1] "your"/"your and your spouse's"
[2] "11,500"/"23,000"
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REFC01
|
CAPTION
|
If You Have Any Questions
|
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REF073
|
DENIAL, PRE-DECISIONAL, PLANNED
ACTION AND TERMINATION NOTICE - REFERRAL LANGUAGE
|
For information about Medicare prescription drug plans or other Medicare issues, visit
www.medicare.gov 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 www.socialsecurity.gov 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.
You can also write or visit any Social Security office. The office that serves your
area is located at:
Social Security
[1]
Telephone:
[2]
If you do call or visit an office, please have this letter with you. It will help
us answer your questions.
Fill-ins:
[1] Field Office address
[2] Field Office telephone number
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|
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REF074
|
AWARD, REVIEW AND CHANGE NOTICE
- REFERRAL LANGUAGE
|
For information about Medicare prescription drug plans or other Medicare issues, visit
www.medicare.gov 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 www.socialsecurity.gov 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.
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REPC01
|
CAPTION
|
If You Want Help With Your Appeal
|
|
|
REP013
|
HELP WITH APPEAL
|
You can have a lawyer, friend, or someone else help you. Your local Social Security
office has a list of groups that can help you with your appeal. These groups can find
a lawyer or give you free legal services if you qualify. There are also lawyers who
do not charge unless you win your appeal.
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