TN 2 (12-05)

Citations:

20 CFR 418.3605 - 418.3680

A. Procedure - Appeal Decision

The Subsidy Determination Reviewer (SDR) will review the information considered in making the initial determination including the information in records available to SSA and any additional information provided and make the decision based on this information. The decision will be recorded on CPMS (Case Processing and Management System) using identifying information (last name, first initial, last 4 digits of SSN) for easy access in event of court review, and updated to the Medicare database. If the individual objects to the telephone hearing being recorded, document in Remarks in CPMS, conduct a case review and issue a decision without the telephone hearing. Access CPMS at http://cpms.ba.ssa.gov/cpms.

If it appears that the SDR can make a fully favorable decision based on available information and the individual agrees, a telephone hearing need not be held. The SDR will document his/her actions and issue the fully favorable decision.

The SDR will input the Determination Effective Date in MAPS which will determine the appeal decision effective date that is passed to the subsidy determination process in all cases other than dismissals.

The SDR decision is binding unless the individual requests judicial review by filing an action in Federal district court.

NOTE: Where the SDR is deciding a new issue, the notice of decision issued by the SDR will include appeal rights.

B. List of Exhibits

All decision notices will include a list of exhibits, i.e., a minimum of MAPS systems data, a copy of the initial determination notice and other notices as appropriate, and information submitted as displayed on the Development Worksheet in MAPS.

C. Procedure - Notice Types

The SDR is responsible for issuing notices in the Document Generation System (DGS). A written notice of the decision will be mailed to the individual at his/her last known address. Generally, we will not send a notice if the premium subsidy stops because of death or if the initial determination is a redetermination that results in no change.

All notices will be stored on the Online Retrieval System (ORS).

The written notice that we send will explain the procedural history and issues of the case:

• What our decision is;

• The reasons for our decision; and

• The effect of our decision on the subsidy

1. Favorable

The SDR will specify the reasons for his/her decision as he/she would if making any special determination.

The subsidy determination system will also send a notice specifying how the change affects the individual’s subsidy eligibility. If the SDR is deciding a new issue, the DGS notice will contain appeal rights.

2. Unfavorable

The SDR will specify the reasons for his/her decision as he/she would if making any special determination. No further notice is sent from the subsidy determination system.

3. Dismissal

The SDR will specify in the dismissal notice the reason for his/her decision to dismiss the request for appeal. The dismissal notice advises the individual of the option to request the dismissal be vacated and the timeframes. The dismissal is final.

D. Procedure - Undeliverables

When notices are returned as undeliverable, the SAU will try to locate the individual. Document efforts to locate the individual on the Report of Contact screen in MAPS; e.g., use of local resources. If a new address is uncovered, remail the notice, enter the new address on the appeal screens in MAPS. This entry will not update the MBR, so you must also enter the new information in POS (see MSOM T2PE 003.001).

See GN 02605.055 for guidance on undeliverable notices.