BASIC (05-05)

A. Purpose/Use

Notice of Termination is used in post-entitlement situations to notify recipient that the subsidy is being stopped. The Notice of Termination is produced by MAPS.

A modified version of the Notice of Termination is sent following a post-entitlement appeal when the appeal results in the subsidy being stopped. The modified version omits the appeals paragraphs.

B. Sample Notice of Termination

Social Security Administration

Medicare Prescription Drug Assistance

Notice of Termination

                                                                 Great Lakes Program Service Center

                                                                 600 West Madison Street

                                                                 Chicago, Illinois 60661-2474

Date: October 4, 2006

Social Security Number: 123-00-6789

JOHN Q. PUBLIC

123 MAIN ST

SPRINGFIELD OH 45501

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.

Your Help Will Terminate

You will no longer be able to get extra help with your Medicare prescription drug plan costs effective January 2007.

Why Your Help Will Terminate

Because of your resources and income, you are not eligible for extra help with your Medicare prescription drug plan costs effective January 2007.

Information 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:

• Stocks, bonds, or other investments.

• Cash Value of Life Insurance

Your resources we count are more 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 have the following yearly income:

• Net self-employment earnings of $2500.

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

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.

Appeal in 10 Days To Keep Getting The Same Help

• 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 stop only if your appeal is denied.

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.

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