BASIC (05-05)

A. Purpose/Use

The Notice of Denial is used to notify an individual of an initial denial determination. The denial notice is automatically generated if an applicant does not contact SSA within 20 days of being sent a pre-decisional notice, or if the information an applicant provides in response to the pre-decisional notice does not change SSA’s determination. This notice is produced by MAPS.

B. Sample Notice of Denial

Social Security Administration

Medicare Prescription Drug Assistance

Notice of Denial

                                                                              Great Lakes Program Service Center

                                                                              600 West Madison Street

                                                                              Chicago, Illinois 60661-2474

                                                                              Date: November 23, 2005

                                                                              Social Security Number: 123-00-6789

JOHN Q. PUBLIC

123 MAIN ST

SPRINGFIELD OH 45501

We have determined 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.

Why You Are Not Eligible For Help With Your Prescription Drug Plan Costs

You are not eligible for extra help to pay your Medicare prescription drug plan costs, also known as subsidy, because your income is 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 and your spouse have the following resources:

• Bank accounts.

• Stocks, bonds, or other investments.

Your resources we count are less than $10,000. 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 and your spouse have the following yearly income:

• Other pensions or annuities of $28,000

Your income we count is 150% or more of the Federal Poverty Level. The enclosed worksheet shows you how we counted your income.

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.

What To Do If Your Situation Changes

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.

If You Disagree With The Decision

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.

If You Want Help With Your 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. 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.

Information About Medicare Savings Programs

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.

How You May Be Able to Receive 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 SSI 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, and you are found eligible, you may lose SSI benefits.

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