Social Security
Administration
Medicare
Prescription Drug Assistance
Pre-Decisional
Notice
Great
Lakes Program Service Center
600
West Madison Street
Chicago,
Illinois 60661-2474
Date:
November 1, 2005
Social
Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
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.
Why You May Not Be Eligible For Help With
Your Prescription Drug Plan Costs
You may not be eligible for a subsidy to help pay your Medicare prescription drug
plan costs because both your resources and income are above the limit established
by law.
Information Used In Making The Decision
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.
You have the following resources:
Your resources we count are more than $20,000. The enclosed worksheet shows you how
we counted your resources.
You have 5 persons 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.
You have the following yearly income:
-
-
•
Your spouse’s wages of $4950
Your income we count is 150% or more of the Federal Poverty Level. The enclosed worksheet
shows you how we counted your income.
If You Disagree With Our Records
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.
If You Are Not Correcting Any 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.
How To Sign Up For A Medicare 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. You can enroll beginning November 15, 2005.
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.
If You Have Any Questions
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
2026
W. Main St.
Springfield
OH 45501
Telephone:
937-325-0674
If you do call or visit an office, please have this letter with you. It will help
us answer your questions.
Regional Commissioner
Enclosure(s):
Resource Worksheet
Income Worksheet