Medicare Part D Subsidy Rules - Section 20 CFR 418.3625(c)

Social Security Administration

§ 418.3625

subsidy you received while your appeal
was pending.
§ 418.3515 How could you qualify for a
subsidy again?
Unless you subsequently qualify as a
deemed eligible person (per 42 CFR
423.773(c)), you must file a new application for a subsidy and meet all the requirements in § 418.3101.
DETERMINATIONS AND THE
ADMINISTRATIVE REVIEW PROCESS
§ 418.3601 When do you have the right
to administrative review?
You have the right to an administrative review of the initial determination
we make about your eligibility and
about your continuing eligibility for a
subsidy and any other matter that
gives you the right to further review as
discussed in § 418.3605. If you are married and living with your spouse and
your spouse’s eligibility for a subsidy
may be adversely affected by our decision upon review, we will notify your
spouse before our review and give him
or her the opportunity to present additional information for us to consider.

cprice-sewell on PRODPC61 with CFR

§ 418.3605 What is an initial determination?
Initial determinations are the determinations we make that are subject to
administrative and judicial review. The
initial determination will state the relevant facts and will give the reasons
for our conclusions. Examples of initial
determinations that are subject to administrative and judicial review include but are not limited to:
(a) The initial calculation of your income and/or resources;
(b) The determination about whether
or not you are eligible for a subsidy
and if so, whether you receive a full or
partial subsidy;
(c) The determination to reduce your
subsidy; and
(d) The determination to terminate
your subsidy.
§ 418.3610 Is there administrative or
judicial review for administrative
actions that are not initial determinations?
Administrative actions that are not
initial determinations may be reviewed
by us, but they are not subject to the

administrative or judicial review process as provided by these sections. For
example, changes in your prescription
drug
program
or
voluntary
disenrollment in the Part D program
are not initial determinations that are
subject to the administrative review
process.
§ 418.3615 Will we mail you a notice of
the initial determination?
(a) We will mail a written notice of
the initial determination to you at
your last known address. Generally, we
will not send a notice if your premium
subsidy stops because of your death or
if the initial determination is a redetermination that your eligibility for a
subsidy and the amount of your subsidy has not changed.
(b) The written notice that we send
will tell you:
(1) What our initial determination is;
(2) The reasons for our determination; and
(3) The effect of our determination on
your right to further review.
(c) We will mail you a written notice
before increasing, reducing, or terminating your subsidy. The notice will
tell you the first month that we plan
to make the change and give you appeal rights. Your appeal rights for a reduction or termination will include the
right to continue to receive your subsidy at the previously established level
until there is a decision on your appeal
request if your appeal is filed within 10
days after you receive our notice.
§ 418.3620 What is the effect of an initial determination?
An initial determination is binding
unless you request an appeal within
the time period stated in § 418.3630(a) or
we revise it as provided in § 418.3678.
§ 418.3625 What is the process for administrative review?
The process for administrative review of initial determinations is either
a hearing conducted by telephone or a
case review. We will provide you with a
hearing by telephone when you appeal
the initial determination made on your
claim, unless you choose not to participate in a telephone hearing. If you
choose not to participate in a telephone hearing, the review will consist

1207

VerDate Aug<31>2005

15:09 May 23, 2007

Jkt 211063

PO 00000

Frm 01217

Fmt 8010

Sfmt 8010

Y:\SGML\211063.XXX

211063

cprice-sewell on PRODPC61 with CFR

§ 418.3630

20 CFR Ch. III (4–1–07 Edition)

of a case review. The hearing will be
conducted by an individual who was
not involved in making the initial determination. The individual who conducts the hearing will make the final
decision after the hearing. If you are
dissatisfied after we have made a final
decision, you may file an action in Federal district court.
(a) Notice scheduling the telephone
hearing. Once you request a telephone
hearing, we will schedule the hearing
and send you a notice of the date and
time of the hearing at least 20 days before the hearing. The notice will contain a statement of the specific issues
to be decided and tell you that you
may designate a personal representative (as defined in 42 CFR 423.772) to
represent you during the proceedings.
The notice will explain the opportunity
and procedure for reviewing your file
and for submitting additional evidence
prior to the hearing. It also will provide a brief explanation of the proceedings, of the right and process to
subpoena witnesses and documents, of
the procedures for requesting a change
in the time or date of your hearing,
and of the procedure for requesting interpreter services.
(b) Opportunity to review your file.
Prior to the telephone hearing, you
will be able to review the information
that was used to make an initial determination in your case. You can provide
us with additional information you
wish to have considered at the hearing.
(c) Hearing waived, rescheduled, or
missed. If you decide you do not want a
hearing by telephone or if you are not
available at the time of the scheduled
hearing, the decision in your case will
be made by a case review. This means
that the decision will be based on the
information in your file and any additional information you provide. You
may ask for a change in the time and
date of the telephone hearing; this
should be done at the earliest possible
opportunity prior to the hearing. Your
request must state your reason(s) for
needing the change in time or date and
state the new time and date you want
the hearing to be held. We will change
the time and date, but not necessarily
to your preferred time or date, of the
telephone hearing if you have good
cause. If you miss the scheduled hear-

ing and the decision in your case is decided by a case review, we will provide
a hearing, at your written request, if
we decide you had good cause for missing the scheduled hearing. Examples of
good cause include, but are not limited
to, the following:
(1) You have attempted to obtain a
representative but need additional
time;
(2) Your representative was appointed within 30 days of the scheduled
hearing and needs additional time to
prepare for the hearing;
(3) Your representative has a prior
commitment to be in court or at another administrative hearing on the
date scheduled for your hearing;
(4) A witness who will testify to facts
material to your case would be unavailable to participate in the scheduled hearing and the evidence cannot
be obtained any other way;
(5) You are unrepresented, and you
are unable to respond to the notice of
hearing because of any physical, mental, educational, or linguistic limitations (including any lack of facility
with the English language) that you
may have; or
(6) You did not receive notice of the
hearing appointment.
(d) Witnesses at hearing. When we determine that it is reasonably necessary
for the full presentation of a case, we
may issue a subpoena to compel the
production of certain evidence or testimony.
§ 418.3630 How do you request administrative review?
(a) Time period for requesting review.
You must request administrative review within 60 days after the date you
receive notice of the initial determination (or within the extended time period if we extend the time as provided
in paragraph (c) of this section). You
can request administrative review in
person, by phone, fax, or mail. If you
miss the time frame for requesting administrative review, you may ask us
for more time to request a review. The
process for requesting an extension is
explained further in paragraph (c) of
this section.

1208

VerDate Aug<31>2005

15:09 May 23, 2007

Jkt 211063

PO 00000

Frm 01218

Fmt 8010

Sfmt 8010

Y:\SGML\211063.XXX

211063