ALSC04

CAPTION

If You Disagree With The Decision

ALSC30

CAPTION

Appeal In 10 Days To Keep Getting The Same Help

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"

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.

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.

CAPC22

CAPTION

ENC008

ENCLOSURE REMARK

Enclosure(s)

MPDC01

CAPTION

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

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

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"

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 get married;

• 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]

MPD170

NOTICE - LISTED COUNTABLE INCOME

Other pensions or annuities of $[1]

MPD171

NOTICE - LISTED COUNTABLE INCOME

Other income of $[1]

MPD172

NOTICE - LISTED COUNTABLE INCOME

Help with household expenses of $[1]

MPD173

NOTICE - LISTED COUNTABLE INCOME

Wages of $[1]

MPD174

NOTICE - LISTED COUNTABLE INCOME

Wages for your spouse of $[1]

MPD175

NOTICE - LISTED COUNTABLE INCOME

Net self-employment earnings of $[1]

MPD176

NOTICE - LISTED COUNTABLE INCOME

Net self-employment earnings for your spouse of $[1]

MPD177

NOTICE - LISTED COUNTABLE INCOME

Net loss from self-employment of $[1]

MPD178

NOTICE - LISTED COUNTABLE INCOME

Net loss from self-employment for your spouse of $[1]

MPD179

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

MPD180

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.

MPD181

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.

MPD182

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.

MPD183

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 get married;

• 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

MPD184

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

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.

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.

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.

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"

REFC01

CAPTION

If You Have Any Questions

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

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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If You Want Help With Your Appeal

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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.