I-3-0-50.Subsidy Appeals Unit and Appeal of Medicare Part D Subsidies

Last Update: 11/20/14 (Transmittal I-3-84)

A. General

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, also known as the Medicare Modernization Act, amended title XVIII of the Social Security Act to establish a Medicare prescription drug coverage program, Medicare Part D, effective January 1, 2006. The Social Security Administration (SSA) administers a program under Medicare Part D to help low-income Medicare beneficiaries receive Part D premium, deductible, and copayment subsidies. SSA processes and makes determinations and decisions on applications, redeterminations, and appeals. The Subsidy Appeals Unit (SAU) within the Office of Appellate Operations processes appeals of initial Medicare Part D Subsidy determinations and Medicare Part D Subsidy redeterminations.

Under the one-step appeals process for Medicare Part D Subsidy determinations, a claimant may choose either a hearing by telephone or a case review (i.e., the decision will be based on the information in the file and any additional information he or she provides). The subsidy determination reviewer in the SAU reviews the information considered in making the initial determination, along with any additional information provided, and makes a decision. If a claimant is dissatisfied with SSA's decision, he or she may file an action in Federal district court.

B. Appeal of Medicare Part D Subsidy Determination

The instructions for processing an appeal of a Medicare Part D Subsidy determination are set forth in the Program Operations Manual System (POMS).

  • POMS HI 03040.001 for an overview of the appeals process for Medicare Part D subsidy determinations;

  • POMS HI 03040.100 for establishing an appeal;

  • POMS HI 03040.200 for processing an appeal;

  • POMS HI 03040.300 for dispositions on appeal;

  • POMS HI 03040.400 for the Federal court remand process;

  • POMS HI 03050.005 for redeterminations that include processing reports of change and subsidy changing events;

  • POMS HI 03050.011 for redetermination of eligibility; and

  • POMS HI 03050.015 for redetermination adjustments and terminations.