Source: http://www.federalregister.com/Browse/Document/usa/na/fr/2005/12/30/05-24633
Timestamp: 2019-03-23 03:26:06
Document Index: 237323142

Matched Legal Cases: ['§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 416', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 416', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 416', '§ 418', '§ 416', '§ 416', '§ 418', '§ 418', 'ART 418', 'art?418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 404', '§ 418', '§ 416', '§ 416', '§ 418', '§ 416', '§ 416', '§ 416', '§ 416', '§ 416', '§ 418', '§ 416', '§ 416', '§ 416', '§ 418', '§ 416', '§ 418', '§ 418', '§ 418', '§ 418', '§ 404', '§ 418', '§ 416', '§ 416', '§ 416', '§ 416', '§ 416', '§ 416', '§ 416', '§ 416', '§ 416', '§ 416', '§ 416', '§ 416', '§ 416', '§ 416', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418', '§ 418']

70 FR 250 pgs. 77664-77685 - Medicare Part D Subsidies
Years > 2005 > December, 2005 > Friday, December 30, 2005
Type: RULEVolume: 70Number: 250Pages: 77664 - 77685
FR document: [FR Doc. 05-24633 Filed 12-29-05; 8:45 am]
RIN 0960-AG03
Section 101 of the Medicare Modernization Act (Pub. L. 108-173), which was enacted into law December 8, 2003, adds sections 1860D-1 through 1860D-24 to the Social Security Act (the Act), and establishes a new Part D program for voluntary prescription drug coverage effective January 1, 2006. The Centers for Medicare Medicaid Services (CMS) has overall responsibility for implementing the voluntary Medicare Part D prescription drug benefit and published final rules on January 28, 2005 at 70 FR 4193. As described in these final rules, we are responsible only for the premium and cost-sharing subsidy (the subsidy) portion of the Medicare Part D prescription drug benefit program. We are authorized to make eligibility determinations, provide appeal procedures, and perform eligibility redeterminations for the Part D subsidy in the 50 States and the District of Columbia. We are not authorized to undertake this task for Medicare beneficiaries who live in the territories or who live outside of the 50 States or the District of Columbia.
Section 702(a)(5) of the Act allows us to make the rules and regulations necessary or appropriate to carry out the functions of SSA. Section 1860D-14 of the Act provides for premium and cost-sharing subsidies of prescription drug coverage for certain individuals with low income and resources. An individual must be entitled to benefits under Medicare Part A or enrolled in Medicare Part B in order to receive a subsidy. Section 1860D-14(a)(3)(B) directs us to make subsidy determinations. It also requires us to provide appeal procedures for subsidy eligibility determinations and to perform redeterminations. (State Medicaid agencies have similar responsibilities that are covered in CMS' final rules. Additionally, CMS will conduct annual redeterminations of deemed status and will reconsider certain CMS low income subsidy (LIS) determinations; CMS LIS reconsideration procedures will be addressed in the agency's operating instructions.) Generally, the agency that processes the subsidy application will handle redeterminations and appeals related to that initial eligibility determination.
• File a subsidy application either with us or with your State Medicaid Agency to see if you qualify for a subsidy; and
• Enroll with an authorized prescription drug provider for the Medicare Part D prescription drug benefit; i.e., a prescription drug plan. (We do not enroll beneficiaries for Medicare Part D. If you are a Medicare beneficiary, you must take the necessary steps to enroll yourself with a participating approved prescription drug plan or Medicare Advantage plan that offers prescription drug coverage. Sections 423.32-423.34 of 42 CFR discuss the enrollment process, including the enrollment of full benefit dual-eligible individuals. You also may obtain information about enrolling on the Internet at www.medicare.gov or by calling CMS at 1-800-Medicare.)
Certain individuals with both Medicare and Medicaid, with Medicare Savings Programs, or with Medicare and receiving SSI payments but who have not enrolled in a prescription drug plan, will be able to take advantage of special enrollment processes. The special enrollment processes are discussed in the preamble to CMS' final rules published January 28, 2005 at 70 FR 4205-4209 and in CMS's regulations at 42 CFR 423.34.
• You must be entitled to benefits under Medicare Part A (Hospital Insurance) and/or enrolled in Medicare Part B (Supplementary Medical Insurance) under title XVIII of the Act;
• You must be enrolled in a Medicare prescription drug plan or Medicare Advantage plan with prescription drug coverage by the end of your enrollment period;
• You must reside in the United States as defined in § 418.3010;
• You (and your living with spouse, if applicable) must meet the income and resource requirements of the subsidy program; and
• You must apply for the subsidy.
• You lose entitlement to or are not enrolled in Medicare Part A and you also lose eligibility for or are not enrolled in Medicare Part B, or
• You do not enroll or you are no longer enrolled with a Medicare prescription drug plan or Medicare Advantage plan with prescription drug coverage.
• Apply for the subsidy with us or your State Medicaid agency, and
• Enroll in Medicare Part D by enrolling in a Medicare prescription drug plan or Medicare Advantage plan with prescription drug coverage.
When you file an application we will determine your eligibility and provide you with appeal rights. If we find that you are eligible for the subsidy, we will also determine whether you should receive a full or partial subsidy. Timely filing also assures that you can receive the subsidy for any months you are eligible. If you inquire orally or in writing about the subsidy and tell us you want to file a subsidy application, or if you partially complete the subsidy application on our Internet Web site, we will use the date of your inquiry or the date we receive a partially completed Internet subsidy application from our Web site as your filing date for the subsidy if the requirements in § 418.3230 are met.
Your application for the subsidy remains in effect until we make a final determination on it. As stated in § 418.3620, our initial determination is binding unless you request an appeal within the time period stated in § 418.3630(a) and our decision on the appeal is binding unless you file an action in Federal district court seeking review of our final decision (see § 418.3675). If you timely file an appeal of our initial determination, your application for the subsidy remains in effect until we make a decision on your appeal. If you are not enrolled in a Medicare Part D plan or Medicare Advantage plan with prescription drug coverage when you file your subsidy application, we will write and tell you about your eligibility for the subsidy and that you must be enrolled in such a plan in order to receive a subsidy.
We will not count all of the money you receive when we determine your eligibility for the subsidy. We will apply certain exclusions to income you receive when we determine countable income. As directed by the new legislation, these exclusions are modeled after the exclusions used in the SSI program. For example, we will exclude up to $20 per month ($240 per year) of your income. In addition, we will exclude from unearned income the first $60 per calendar quarter of income that is irregular or infrequent; e.g., cash received as a birthday gift, and the first $30 per calendar quarter of earned income that is irregular or infrequent. We will also exclude all interest and dividends.
We will exclude up to $65 per month ($780 per year) and one-half of the remainder of your earned income (or your and your spouse's combined earned income). We also will exclude a portion of earned income if you are disabled under Social Security rules and have expenses related to your impairment that you must pay in order for you to work. We call these expenses impairment-related work expenses. Similarly, we will exclude a portion of your earned income if you are blind under Social Security rules and have expenses that must be paid in order for you to work. We will apply these exclusions based on these percentages in lieu of determining the actual work related expense in each case. The amount we exclude will be equal to the average percentage of gross earnings excluded for SSI recipients who have such expenses. Initially, the exclusion for impairment-related work expenses will be 16.3 percent of the gross earnings; the exclusion for blind work expenses will be 25 percent of the gross earnings. However, if you have expenses that exceed the average, we will give you the opportunity to present evidence of your actual expenses and adjust the amount of earned income excluded accordingly. We may adjust the percentages if the average percentage of gross earnings excluded for SSI recipients with disability related or blind work expenses changes. If we make such a change we will publish a notice in the Federal Register .
We have a process for you to appeal our eligibility determination on your subsidy application, and our determinations of whether you can receive a full or partial subsidy, of an adjustment to your subsidy, or of a termination of your subsidy eligibility. We also explain the rights of your spouse whose eligibility could be adversely affected by your appeal. In these final rules, the term "the appeal process," means the same as "the administrative review process," and we use these terms interchangeably throughout.
• An individual who is authorized to act on behalf of the applicant;
• If the applicant is incapacitated or incompetent, someone acting responsibly on his or her behalf, or
• An individual of the applicant's choice who is requested by the applicant to act as his or her representative in the application process.
You must contact us within 60 days of the date you receive notice of the initial determination to ask for an appeal of your subsidy determination. If you miss the deadline for requesting an appeal, you can request more time if you can show us you have good cause for missing the deadline. Once we make a decision on your appeal, we will send you a written notice explaining our decision. If you are dissatisfied with our final decision, you may file an action in Federal district court. As we explain in § 418.3670, if we dismiss your appeal, we will mail a written notice of the dismissal to you, but the dismissal is not subject to judicial review and is binding on you unless we vacate it.
The issues that we will review are the issues with which you disagree. We may consider other issues, but we will provide you with advance notice of these other issues, as explained in § 418.3625.
We may correct clerical errors if discovered within 60 days of the date of our initial determination. We will notify you of our revised determination as explained in § 418.3678.
• Section 418.3001 describes what subpart D is about, lists the groups of sections, and the subject of each group.
• Section 418.3005 explains that the purpose of the subsidy program is to offer help with prescription drug costs to individuals with limited financial means who meet specific requirements.
• Section 418.3010 contains definitions of terms used throughout this subpart.
• Section 418.3101 lists the requirements that you must meet to establish eligibility for a subsidy.
• Section 418.3105 provides a cross-reference to CMS' regulations concerning who does not need to file an application for a subsidy.
• Section 418.3110 explains what happens when you apply for a subsidy.
• Section 418.3115 describes what will prevent you from becoming eligible for a subsidy, even if you meet the requirements in § 418.3101.
• Section 418.3120 describes the changes in your circumstances that may affect your eligibility for a subsidy or whether you can receive a full or partial subsidy, explains when we may make a redetermination of your eligibility when your circumstances change, and explains that we will notify you of our determination.
• Section 418.3123 explains when a change in your subsidy is effective.
• Section 418.3125 defines the term "redetermination" and explains when we conduct redeterminations.
• Section 418.3201 explains that an application is usually necessary for a subsidy and why.
• Section 418.3205 explains when an application for a subsidy becomes a claim for a subsidy.
• Section 418.3210 describes an application for a subsidy.
• Section 418.3215 explains who may file an application for a subsidy.
• Section 418.3220 explains when we consider an application for a subsidy filed and lists places it can be filed.
• Section 418.3225 explains how long an application for a subsidy will remain in effect.
• Section 418.3230 explains when we will use the date you make an oral or written inquiry indicating your intent to file for the subsidy as your subsidy application filing date.
• Section 418.3301 provides the general definition of income that will be used for subsidy determinations.
• Section 418.3305 provides a general description of what is not considered income for purposes of determining eligibility for a subsidy and if eligible, whether you should receive a full or partial subsidy.
• Section 418.3310 explains whose income will be counted when we determine eligibility for a subsidy and if eligible, whether you should receive a full or partial subsidy.
• Section 418.3315 describes earned income.
• Section 418.3320 explains how we count earned income, including when it is considered received, how we count net earnings from self-employment, how we count royalties and honoraria, and how we determine the time periods for which the earned income is counted.
• Section 418.3325 explains that not all earned income will be counted and lists the earned income exclusions that may apply.
• Section 418.3330 provides the general definition of unearned income.
• Section 418.3335 describes the types of unearned income that will be counted.
• Section 418.3340 describes how we count unearned income, including when it is considered received, how we determine how much of your income is countable, and how we determine the time periods for which the unearned income is counted.
• Section 418.3345 explains how we will determine the value of unearned income, if any, received in the form of in-kind support and maintenance.
• Section 418.3350 explains that not all unearned income is countable and lists the exclusions that may apply.
• Section 418.3401 provides the general definition of resources that will be used for purposes of subsidy eligibility determinations.
• Section 418.3405 describes the types of resources that are considered for purposes of subsidy eligibility determinations and lists the type of resources that are considered liquid.
• Section 418.3410 explains whose resources will be counted.
• Section 418.3415 explains that we determine the value of countable resources as of the first day of the month for which a determination will be made.
• Section 418.3420 explains how we count funds held in financial institution accounts.
• Section 418.3425 provides a list of assets that will not be counted as resources.
• Section 418.3501 explains the types of events that could cause us to increase or reduce your subsidy or to terminate your eligibility for a subsidy.
• Section 418.3505 describes the effects of increases, reductions, and terminations of subsidies.
• Section 418.3510 explains that before we increase, reduce, or terminate your subsidy, we must send you a written notice with appeal rights.
• Section 418.3515 explains that after we terminate a subsidy, you must generally file a new application to be eligible for a subsidy again.
• Section 418.3601 explains your rights and your spouse's rights under the administrative review process.
• Section 418.3605 explains that initial determinations are determinations we make that are subject to administrative and judicial review and provides examples of determinations that are initial determinations.
• Section 418.3610 lists administrative actions that are not initial determinations. Although we may review these actions, they are not subject to administrative or judicial review.
• Section 418.3615 explains that we will mail you a notice whenever we make an initial determination in your case. The notice will tell you what our determination is, our reasons for making the determination, and your right to request an appeal of the determination.
• Section 418.3620 explains that an initial determination is binding unless you request an appeal within the stated time period or we revise it as explained in § 418.3678.
• Section 418.3625 describes the administrative review process. This section also explains that if you are dissatisfied with our final decision, you may request judicial review.
• Section 418.3630 explains how to file a request for a hearing and that you may ask for more time to request your appeal if you had good cause for missing the 60-day deadline.
• Section 418.3635 explains who can request administrative review on your behalf.
• Section 418.3640 explains the standards we follow in determining whether you had good cause for missing the 60-day deadline to request a review.
• Section 418.3645 explains under what circumstances the decision-maker may be disqualified.
• Section 418.3650 explains that we make a decision based on the information we have and any other information you provide.
• Section 418.3655 explains that we will send you a notice of our decision on the appeal that gives you the right to judicial review.
• Section 418.3665 explains under what circumstances your request for administrative review may be dismissed.
• Section 418.3670 explains how we will notify you if your request for administrative review is dismissed.
• Section 418.3675 explains that our final decision on appeal is binding unless you request judicial review within the stated time or we revise it as explained in § 418.3678.
• Section 418.3678 explains the process for correcting Agency clerical errors.
• Section 418.3680 explains what happens if a Federal court remands your case to us.
Response: As noted in the preamble to the proposed rules, these rules only address our processing of applications, redeterminations and appeals. We have no authority to regulate the States in this area. CMS oversees the State's participation in this program and issued its own rules that the States are expected to follow on January 28, 2005 (70 FR 4193). CMS also issued additional guidance to the States in a document dated May 25, 2005. This guidance is available on CMS' Web site at http://www.cms.hhs.gov/States/03_lowincomesubsidy.asp.
In evaluating this comment and reviewing the relevant proposed rules, we detected an inadvertent error in § 418.3225(c). That section stated that individuals who applied for the subsidy but were not yet entitled to Medicare Part A or enrolled in Medicare Part B would receive a letter explaining their eligibility for the subsidy provided they become so entitled and/or enrolled. However, because entitlement to Medicare Part A or enrollment in Medicare Part B is a criterion for eligibility for a subsidy (in addition to enrollment in a Part D plan), we will not be able to make a subsidy eligibility determination in the absence of entitlement to or enrollment in Medicare Part A or Part B. (The CMS regulations at 42 CFR 423.774 permit a subsidy eligibility determination to be made for Medicare beneficiaries not yet enrolled in a prescription drug plan, but they do not provide similar authority regarding individuals who do not yet have Medicare coverage.) Therefore, we are revising § 418.3225(c) to state that if you apply for the subsidy before you are entitled to Medicare Part A and/or enrolled in Medicare Part B but you appear to be in an enrollment period, the notice we send will advise you that we will not take any action on your application until you become entitled to Medicare Part A and/or enrolled in Medicare Part B. If you do not appear to be in an enrollment period, the notice will advise you that you are not eligible for the subsidy because you are not entitled to Medicare Part A or enrolled in Medicare Part B. This letter will also explain your appeal rights.
Response: Although this is a valid concern that warrants further consideration, we have not adopted this comment. The only alternate language format for notices we are currently able to offer is Spanish; however, this is not available to Railroad Retirement beneficiaries because we do not have a record of their preference for a Spanish notice. We will investigate expanding our ability to offer other alternate language formats in the future.
Response: Since the Act does not address the effect of the subsidy on other Federal programs or provide a specific exclusion, and since we have no authority to instruct other agencies, this recommendation is beyond the scope of these rules. However, CMS has prepared several fact sheets explaining the impact of the subsidy on various Federal programs. Those fact sheets are available at CMS' Web site, www.Medicare.gov. In evaluating this comment, we noticed that our proposed rules were not sufficiently clear about how income excluded by other Federal programs would be treated for purposes of determining eligibility for the subsidy. Therefore, we are revising § 418.3350(b), by adding a reference to § 416.1124(b) of our rules to clarify that income, excluded by the SSI program because it is excluded under other Federal statutes, will also be excluded for purposes of determining eligibility for the subsidy.
Response: We agree with this comment and have revised § 418.3105 to clarify that if beneficiaries have deemed eligibility status because they receive Medicaid coverage, are enrolled in a Medicare Savings Program within their State, or receive SSI and have Medicare, then their subsidy is effective with the first month they have deemed eligibility status.
Response: Following the guidelines in CMS regulations at 42 CFR 423.780, we will determine eligibility and subsidy percentage for a calendar year. CMS will make the subsidy amount determination. These determinations will remain in effect throughout the year, unless a beneficiary reports a subsidy-changing event described in § 418.3120(a) or the beneficiary becomes deemed eligible for a full subsidy.
Response: The rules state at § 418.3120(b)(1) that we will use information we receive from the beneficiary or from data exchanges with Federal agencies to determine the correct subsidy amount. Depending on the new information we receive, the subsidy may increase, decrease, or remain unchanged. Except as provided in § 418.3120(a), we will use any income or resource information obtained via data exchange when we determine a person's continuing eligibility for the next calendar year.
Comment: Three commenters asked that we provide greater detail in the regulations about how we will conduct redeterminations of subsidy eligibility. They suggested that we adopt a "passive" redetermination process, in which we advise the beneficiary about the information we have, and the beneficiary is only required to respond if the information is inaccurate. They suggested that we limit the number of times we will conduct a redetermination in a given period. The commenters explain that this would enable a simple redetermination process that would not be a burden on us or on beneficiaries.
Response: We agree that the redetermination process should be simple and should not be burdensome. For these reasons, we plan to use a "passive" redetermination process for a beneficiary's first scheduled redetermination. Further, we do not plan to conduct a redetermination for every beneficiary every year, but will instead schedule redeterminations based on the likelihood that an individual's situation may change. We expect this process to fulfill our responsibility to maintain the integrity and accuracy of the subsidy program, while minimizing burdens placed on us and on beneficiaries. However, without further experience we cannot commit ourselves to the "passive" redetermination process or any particular redetermination frequency, and therefore we are not revising the regulation to address these issues. Experience may tell us that a different process better serves the integrity of the program and interests of beneficiaries. The law gives us broad discretion, which we exercise in these regulations, to determine the procedures for conducting redeterminations. However, based on these comments, we are changing § 418.3110(c) and § 418.3225(b) to eliminate the statement that we will terminate subsidy eligibility if an individual has not yet enrolled in a prescription drug plan at the time of a redetermination. We are making this change because some situations could develop in the future where an individual will be enrolled in a drug plan but the effective date will be later than our redetermination. We plan to monitor our redetermination process in order to determine whether any further changes are warranted.
Comment: Four commenters suggest that changes that would affect the subsidy amount, such as in income, resources, household composition, or enrollment in a Medicare Savings Program, could be reported at any time and should become effective immediately, or a month after the month of the report of the change, rather than delaying the effect. They are concerned about the fact that these changes are not effective until the January following the report. They believe this would be disadvantageous for beneficiaries who have a decrease in income or resources, but will continue to receive the same subsidy amount until a redetermination is completed.
Response: Section 418.3110(d)(3) of these final rules clarify that a person who has been denied eligibility for a prescription drug subsidy may reapply any time their situation changes. Individuals already receiving a subsidy may report significant changes at any time. However, in keeping with the direction provided by section 1860D-14 of the Act, we established a simplified application form and process for this program. One technique that we adopted to maintain a simplified process was that eligibility determinations will be based on determinations of yearly income and resource amounts. The determination remains in effect for a calendar year unless the beneficiary reports one of the six subsidy changing events listed in the rules, appeals the initial determination, or becomes eligible for a program that would cause deemed eligibility for a full subsidy. This approach ensures that the individuals found eligible for subsidies will have continuous eligibility and will not be impacted by monthly income changes. Also, beneficiaries are not burdened with reporting responsibilities. This comment did alert us to one possible subsidy-changing event that we inadvertently omitted, that of a change in household composition due to a separated married couple resuming living together. We have revised § 418.3120 to reflect this change.
Comment: One commenter said that we should use a term such as "helper" as synonymous with "representative" and specify that representatives are always allowed to sign an application.
• Allow more time to submit requested information, so that applicants who may be mentally or physically unable to comply will have an adequate opportunity to respond.
• Clarify how we will assist when an applicant fails to submit requested information.
• Contact the applicant and explain what is needed to complete the application.
• Give the applicant 180 days to complete the application.
• Specify a time frame to process incomplete applications and clarify the rules we will follow to process them.
• State that we will send a written notice giving a deadline to submit the required information.
Comment: Five commenters recommended that we revise § 418.3335 to remove in-kind support and maintenance from consideration as countable income. They asserted that under MMA, we have the authority to exclude consideration of in-kind support and maintenance in making eligibility determinations. Four of the five commenters pointed out that the Medicare Savings Program uses SSI methodology to determine countable income but the model Medicare Savings Program application created by CMS does not include in-kind support and maintenance. They further pointed out that it could be difficult for individuals to provide information about household expenses which might discourage potential beneficiaries from filing a claim.
Comment: One commenter recommended that we simplify the in-kind support and maintenance determination described in § 418.3345 by allowing beneficiaries to use a default dollar value equal to one-third of the SSI Federal benefit rate unless the beneficiary alleges a dollar amount less than the default value.
Response: We do not agree that permitting beneficiaries to use a default dollar value equal to one-third of the SSI Federal benefit rate would simplify in-kind support and maintenance determinations. In addition, we are concerned that offering individuals the option of using a default amount could inappropriately encourage individuals to allege the default amount instead of the actual amount which could be lower and, therefore, beneficial to the individual. Section 418.3345(b) of the final rules states that we will count in-kind support and maintenance as income only up to one-third of the applicable SSI Federal benefit rate. Section 418.3345(a) of the final rules states that the amount of income derived from in-kind support and maintenance is the current market value of the food and shelter provided by other people. When the current market value of the in-kind support and maintenance is less than one-third of the applicable Federal benefit rate, only the current market value is counted as income. However, to make this clear in the regulations, we have revised § 418.3345(b) to state that if the current market value of in-kind support and maintenance the individual receives is worth less than one-third of the applicable monthly SSI Federal benefit rate, we count only the current market value as income.
Comment: One commenter stated that the rules in § 418.3345 do not offer a streamlined approach that enables beneficiaries to determine how much, if any, in-kind support and maintenance they receive. The commenter recommended that we reduce the amount of the maximum countable in-kind support and maintenance to below one-third of the Federal SSI benefit rate. The commenter further recommended that we provide a streamlined methodology for beneficiaries to calculate in-kind support and maintenance.
Comment: Nine commenters stated that the rules in § 418.3325 should provide an exclusion for earned income received by a Social Security Disability Insurance (SSDI) beneficiary during a trial work period or an unsuccessful work attempt. The same commenters stated that the regulation also should provide an exclusion for earned income of an SSDI beneficiary received as a result of a work-related subsidy or special condition. Under SSDI rules, a work-related subsidy exclusion is applied when an individual's earnings exceed the reasonable value of the work performed, and we count only the pay that is actually earned. Under SSDI rules, if work is done under special conditions, we may determine that the work does not show that the individual can perform substantial gainful activity. These commenters also stated that the regulations should permit SSDI beneficiaries to deduct unincurred business expenses when determining countable self employment income. An unincurred business expense occurs when a sponsoring agency or another person pays certain business expenses for the individual who is attempting to work. The commenters stated that not providing these earned income exclusions would be a disincentive for SSDI beneficiaries who might not try working because their earnings could cause them to lose eligibility for the subsidy.
Comment: Fourteen commenters stated that the rules in § 418.3325(b)(5) and (b)(7) should provide that impairment related work expenses (IRWE) and blind work expenses (BWE) should exclude the average percentage of gross earnings or the actual expenses, whichever is greater.
Response: The rules in § 418.3325(b)(5) and (b)(7) already provide that actual expenses for IRWE and BWE will be used if they are greater than the average percentage of such expenses. If the actual expenses are not greater, then the average percentage will be excluded automatically when the individual indicates on the application that he or she has such expenses.
Response: The specific procedures and timeline for determining higher than average IRWE and BWE expenses will not be addressed in the regulations. These are operational issues and not appropriate to include in regulations. However, § 418.3325 clearly states that we will exclude greater than average IRWE or BWE expenses when the individual's actual IRWE or BWE expenses are greater than the average. The notices that we send to beneficiaries will state how much income we are counting and how much income is excluded because of IRWE or BWE. The notices will inform the beneficiaries to contact us if they disagree with our income determination. If a beneficiary contacts us with a question about the IRWE or BWE exclusion amount, we will help the individual to establish the actual amount of IRWE or BWE expenses that should be excluded.
Response: We agree with the commenter that the process for proving higher than average IRWE and BWE should be as easy as possible for beneficiaries. However, we do not believe a change in the regulation is necessary. The procedures we have developed are based on the recognition that determining dollar amounts for IRWE or BWE can be difficult because of the wide variety of expenses that potentially qualify for this exclusion. Therefore, under our procedures our staff will assist beneficiaries establish a higher than average IRWE or BWE exclusion and in obtaining any documentation that might be required to establish a higher than average IRWE or BWE exclusion. We will issue operating instructions explaining these procedures.
Response: The procedures for determining the exclusion of expenses associated with service dogs or guide dogs are provided in our operating instructions and will not be addressed in these regulations. Our procedures exclude expenses associated with service dogs and guide dogs and all associated expenses under either the IRWE or BWE exclusion if the dogs are needed for employment-related activity. To make it clear that BWE exclusions such as guide dogs also apply to subsidy determinations, we are adding a cross-reference in § 418.3325(b)(7) that refers to the SSI BWE provision in § 416.1112(c)(8) of our rules.
Response: We have clarified § 418.3340(f) of the final rules to state that we will not count the amount of the cost-of-living adjustment (COLA) for Social Security benefits for any month before the Federal poverty guidelines are published. Section 1905(p)(2)(D)(i) of the Act provides that the income of an individual who is entitled to monthly insurance benefits under title II shall not include any amounts attributable to a COLA for each month through the month following the month in which the annual revision of the Federal poverty guidelines are published. However, the statutory authority to not count the COLA applies only to monthly insurance benefits under title II and not to other Federal benefits. Therefore, we have also revised § 418.3120(a)(7) for consistency.
Comment: One commenter stated that our description in § 418.3405 of liquid resources as those which can be converted to cash within 20 workdays is ambiguous. The commenter stated that § 418.3405 of the rules should include a finite list of the resources that will be counted and a statement that anything not listed will not be counted.
Response: The purpose of § 418.3405 is to describe the types of financial accounts and instruments that will be counted as resources. Liquid resources are resources that are held in financial accounts or other instruments that can be converted to cash within 20 workdays. We will presume that these types of resources can be converted to cash within 20 workdays and are countable. However, if the individual establishes that a particular resource (other than nonhome real property) cannot be converted to cash within 20 workdays, we will not count it as a resource in the subsidy determination. We refer to "liquid resources" in order to differentiate them from "non-liquid" resources which, except for equity in nonhome real property, will not be counted for purposes of determining subsidy eligibility ( e.g. , vehicles, household goods, jewelry, musical instruments, etc.). We are adding language to § 418.3405 to clarify that "20 days" means "20 workdays." This is how we described this rule in the preamble of the Notice of Proposed Rulemaking (NPRM) and it was an unintended omission that we did not say "workdays" in § 418.3405 in the NPRM.
To further improve the clarity of what resources are generally considered liquid, we will add the following examples to the list of resources that are ordinarily considered liquid, "trusts if they are revocable or if the trust beneficiary can direct the use of the funds in the trust." We consider a revocable trust to be a liquid resource because it can be converted to cash. Also, if a trust beneficiary can direct the use of the funds in a trust, the funds in the trust are a liquid resource because the beneficiary can use those funds for support and maintenance.
Comment: One commenter recommended that we automatically exclude $1,500 in assets for all beneficiaries under the burial exclusion in § 418.3425(j). The commenter expressed concern that some beneficiaries could be disadvantaged if they did not understand the burial exclusion question and answered it incorrectly.
Response: Although we did not specifically mention prepaid burial contracts and burial trusts in this regulation, irrevocable burial contracts and irrevocable burial trusts will not be considered as countable resources for purposes of determining eligibility for the subsidy. With the exception of equity in nonhome real property, we count only liquid resources for purposes of subsidy eligibility. We have revised § 418.3425(b) to clarify that irrevocable burial trusts and the irrevocable portion of prepaid burial contracts will not be counted as resources.
Comment: One commenter pointed out that § 418.3425(j) provides for a $1,500 exclusion of funds being saved explicitly for burial expense but does not incorporate by reference the SSI burial fund exclusion in § 416.1231(b) of our rules. Section 416.1231(b) of our rules describes the types of funds covered under this exclusion for SSI purposes as well as exceptions to the amount of excluded burial funds. Because § 418.3425(j) does not incorporate § 416.1231(b) of our rules by reference, the commenter recommends that our operating instructions should discuss the types of resources that will be considered excludable as burial funds and any applicable reductions to the excluded amount of burial funds.
Response: We did not incorporate § 416.1231(b) of our rules by reference because the $1,500 burial exclusion applicable for SSI resource determinations is different from the $1,500 burial exclusion applicable to subsidy determinations. Our operating instructions make it clear that for purposes of determining subsidy eligibility, the $1,500 burial fund exclusion is applied to any of a beneficiary's countable liquid resources if the beneficiary states that he or she expects that some of the money will be used for burial expenses. Our operating instructions also make it clear that this $1,500 exclusion, unlike the SSI burial fund exclusion, is not reduced by the value of other burial arrangements that the beneficiary may have such as life insurance, a prepaid burial contract, or a burial trust. We believe that this approach is consistent with Congressional intent that we simplify the subsidy program. However, as explained earlier we will count revocable burial contracts and revocable burial trusts as resources.
Response: When we receive information after an appeal has been filed that would result in a favorable appeal determination, we will make our determination using the new information received while the appeal is pending. Also, if we discover clerical errors within 60 days after we have made an initial determination or decision, we will correct those errors and send notice of our revised determination with appeal rights to a hearing. We have added a new section to these rules at § 418.3678 to clarify this.
We believe that the subsidy hearing provides a simple appeals process that ensures subsidy applicants receive decisions quickly. It also provides an opportunity for a personal contact with the hearing decision-maker who is reviewing the initial determination on the subsidy claim and making the appeal decision. A hearing by telephone does not require activities such as travel to a hearing, and thus gives the individual quick and easy access, generally in his or her own home, to the appeal decision-maker. Consequently, the appeals process established in these rules provides an efficient and effective means for discussing the issues in question. We plan to provide individuals who are hearing-impaired or non-English speaking the special accommodations they need.
In addition to any changes already discussed, we have made a few other non-substantive editorial corrections.
We have consulted with the Office of Management and Budget (OMB) and determined that these final rules meet the criteria for a significant regulatory action under Executive Order 12866, as amended by Executive Order 13258. Thus, they were reviewed by OMB. Any effect on the economy is attributable to the legislation, not to these final rules. For an analysis of the economic impact of the entire Medicare Part D program, see CMS' final rules published in the Federal Register on January 28, 2005 at 70 FR 4454 through 4524.
We certify that these final rules will not have a significant economic impact on a substantial number of small entities as they affect individuals only. Therefore, a regulatory flexibility analysis as provided in the Regulatory Flexibility Act, as amended, is not required. However, for an analysis of the economic impact of the entire Medicare Part D program, see CMS' final rules published in the Federal Register on January 28, 2005 at 70 FR 4454 through 4524.
The Paperwork Reduction Act (PRA) of 1995 says that no persons are required to respond to a collection of information unless it displays a valid OMB control number. In accordance with the PRA, SSA is providing notice that OMB has approved the information collection requirements contained in §§ 418.3120 through 418.3670 of these final rules. The OMB Control Number for these collections is 0960-0702, expiring May 31, 2008.
(Catalog of Federal Domestic Assistance Program Nos. 93.773, Medicare-Hospital Insurance and 93.774, Medicare-Supplementary Medical Insurance Program)
Administrative practice and procedure, Aged, Blind, Disability benefits, Public assistance programs, Reporting and recordkeeping requirements, Supplemental Security Income (SSI), Medicare subsidies.
PART 418-MEDICARE SUBSIDIES
Subparts A-C-[Reserved]
Subpart D-Medicare Part D Subsidies
Sec. 418.3001 What is this subpart about?418.3005 Purpose and administration of the program.418.3010 Definitions.
418.3101 How do you become eligible for a subsidy?418.3105 Who does not need to file an application for a subsidy?418.3110 What happens when you apply for a subsidy?418.3115 What events will make you ineligible for a subsidy?418.3120 What happens if your circumstances change after we determine you are eligible for a subsidy?418.3123 When is a change in your subsidy effective?418.3125 What are redeterminations?
418.3201 Must you file an application to become eligible for a subsidy?418.3205 What makes an application a claim for a subsidy?418.3210 What is a prescribed application for a subsidy?418.3215 Who may file your application for a subsidy?418.3220 When is your application considered filed?418.3225 How long will your application remain in effect?418.3230 When will we use your subsidy inquiry as your filing date?
418.3301 What is income?418.3305 What is not income?418.3310 Whose income do we count?418.3315 What is earned income?418.3320 How do we count your earned income?418.3325 What earned income do we not count?418.3330 What is unearned income?418.3335 What types of unearned income do we count?418.3340 How do we count your unearned income?418.3345 How do we determine the value of in-kind support and maintenance?418.3350 What types of unearned income do we not count?
418.3401 What are resources?418.3405 What types of resources do we count?418.3410 Whose resources do we count?418.3415 How do we determine countable resources?418.3420 How are funds held in financial institution accounts counted?418.3425 What resources do we exclude from counting?
418.3501 What could cause us to increase or reduce your subsidy or terminate your subsidy eligibility?418.3505 How would an increase, reduction or termination affect you?418.3510 When would an increase, reduction or termination start?418.3515 How could you qualify for a subsidy again?
418.3601 When do you have the right to administrative review?418.3605 What is an initial determination?418.3610 Is there administrative or judicial review for administrative actions that are not initial determinations? 418.3615 Will we mail you a notice of the initial determination?418.3620 What is the effect of an initial determination?418.3625 What is the process for administrative review?418.3630 How do you request administrative review?418.3635 Can anyone request administrative review on your behalf?418.3640 How do we determine if you had good cause for missing the deadline to request administrative review?418.3645 Can you request that the decision-maker be disqualified?418.3650 How do we make our decision upon review?418.3655 How will we notify you of our decision after our review?418.3665 Can your request for a hearing or case review be dismissed?418.3670 How will you be notified of the dismissal?418.3675 How does our decision affect you?418.3678 What is the process for correcting Agency clerical errors?418.3680 What happens if your case is remanded by a Federal court?
Secs. 702(a)(5) and 1860D-1, 1860D-14 and -15 of the Social Security Act (42 U.S.C. 902(a)(5),1395w-101, 1395w-114, and -115).
The purpose of the subsidy program is to offer help with the costs of prescription drug coverage for individuals who meet certain income and resources requirements under the law as explained in this subpart. The Centers for Medicare Medicaid Services (CMS) in the Department of Health and Human Services has responsibility for administration of the Medicare program, including the new Medicare Part D Voluntary Prescription Drug Benefit Program. We notify Medicare beneficiaries who appear to have limited income, based on our records, about the availability of the subsidy if they are not already eligible for this help, and take applications for and determine the eligibility of individuals for a subsidy.
(1) CMS means the Centers for Medicare Medicaid Services in the Department of Health and Human Services.
(6) We , our or us means the Social Security Administration (SSA).
(5) Family size , for purposes of this subpart, means family size as defined in 42 CFR 423.772.
(6) Federal poverty line , for purposes of this subpart, has the same meaning as Federal poverty line in 42 CFR 423.772.
Unless you are deemed eligible as explained in § 418.3105 and 42 CFR 423.773(c), you are eligible for a Medicare Part D prescription drug subsidy if you meet all of the following requirements:
(b) You are enrolled in a Medicare prescription drug plan or Medicare Advantage plan with prescription drug coverage. We can also determine your eligibility for a subsidy before you enroll in one of the above programs. However, as explained in § 418.3225(b), if we determine that you would be eligible for a subsidy before you have enrolled in a Medicare prescription drug plan or Medicare Advantage plan with prescription drug coverage, you must enroll in one of these plans to actually receive a subsidy.
(c) You reside in the United States as defined in § 418.3010.
(d) You (and your spouse, if applicable) meet the income requirements as explained in §§ 418.3301 through 418.3350 and 42 CFR 423.773.
(e) You (and your spouse, if applicable) meet the resources requirements as explained in §§ 418.3401 through 418.3425 and 42 CFR 423.773.
(f) You or your personal representative file an application for a subsidy as explained in §§ 418.3201 through 418.3230.
(a) When you or your personal representative apply for a subsidy, we will ask for information that we need to determine if you meet all the requirements for a subsidy. You must give us complete information. If, based on the information you present to us, you do not meet all the requirements for eligibility listed in § 418.3101, or if one of the events listed in § 418.3115 exists, or you fail to submit information we request, we will deny your claim.
(b) If you meet all the requirements for eligibility listed in § 418.3101, or you meet all the requirements except for enrollment in a Medicare Part D plan or Medicare Advantage plan with prescription drug coverage, we will send you a notice telling you the following:
(3) What you may do if your circumstances change as described in § 418.3120; and
(d) If you do not meet all the requirements for eligibility listed in § 418.3101 or if § 418.3115 applies to you except for enrollment in a Medicare Part D plan or Medicare Advantage plan with prescription drug coverage as described in § 418.3225, we will send you a notice telling you the following:
Unless you are a person covered by § 418.3105, in addition to meeting other requirements, you or your personal representative must file an application to become eligible for a subsidy. If you believe you may be eligible for a subsidy, you should file an application. Filing a subsidy application does not commit you to participate in the Part D program. Filing an application will:
(a) You, or someone acting on your behalf as described in § 418.3215, complete an application on a form prescribed by us;
(b) You, or someone acting on your behalf as described in § 418.3215, file the application with us pursuant to § 418.3220; and
If you choose to apply with SSA, you must file for the subsidy on an application prescribed by us. A prescribed application may include a printed form, an application our employees complete on computer screens, or an application available online on our Internet Web site ( www.socialsecurity.gov ). See § 418.3220 for places where an application for the subsidy may be filed and when it is considered filed.
(a) General rule. We consider an application for a subsidy as described in § 418.3210 to be filed with us on the day it is received by either one of our employees at one of our offices or by one of our employees who is authorized to receive it at a place other than one of our offices or it is considered filed on the day it is submitted electronically through our Internet Web site. If a State Medicaid agency forwards to us a subsidy application that you gave to it, we will consider the date you submitted that application to the State Medicaid agency as the filing date. (See 42 CFR 423.774 for applications filed with a State Medicaid agency.)
(2) We may consider an application to be filed on the date a written or oral inquiry about your subsidy eligibility is made, or the date we receive a partially completed Internet subsidy application from our Internet Web site where the requirements set forth in § 418.3230 are met.
§ 418.3225 How long will your application remain in effect?
§ 418.3230 When will we use your subsidy inquiry as your filing date?
(b) The inquiry, whether in person, by telephone, or in writing, is directed to an office or an official described in § 418.3220, or a partially completed Internet subsidy application is received by us;
(c) You or your personal representative (as defined in 42 CFR 423.772) file an application (as defined in § 418.3210) within 60 days after the date of the notice we will send in response to the inquiry. The notice will say that we will make an initial determination of your eligibility for a subsidy, if an application is filed within 60 days after the date of the notice. We will send the notice to you. Where you are a minor or adjudged legally incompetent and your personal representative made the inquiry, we will send the notice to your personal representative; and
(a) We count your income. If you are married and live with your spouse in the month you file for a subsidy, or when we redetermine your eligibility for a subsidy as described in § 418.3125, we count your income and your spouse's income regardless of whether one or both of you apply or are eligible for the subsidy.
(b) We will determine your eligibility based on your income alone if you are not married or if you are married but you are separated from your spouse (i.e., you or your spouse move out of the household and you are no longer living with your spouse) at the time you apply for a subsidy or when we redetermine your eligibility for a subsidy as described in § 418.3125.
(c) If your subsidy is based on your income and your spouse's income and we redetermine your subsidy as described in § 418.3120(b)(1), we will stop counting the income of your spouse in the month following the month that we receive a report that your marriage ended due to death, divorce, or annulment; or a report that you and your spouse stopped living together.
(d) If your subsidy is based on your income and your spouse's income, we will continue counting the income of both you and your spouse if one of you is temporarily away from home as described in § 404.347 of this chapter.
§ 418.3320 How do we count your earned income?
(d) In-kind earned income. We count the current market value of in-kind earned income. For purposes of this part, we use the definition of current market value in § 416.1101 of this chapter. If you receive an item that is not fully paid for and you are responsible for the unpaid balance, only the paid-up value is income to you (see example in § 416.1123(c) of this chapter).
§ 418.3325 What earned income do we not count?
(2) Earned income which is received infrequently or irregularly as explained in § 416.1112(c)(2) of this chapter;
(3) Any portion of the $20 per month exclusion described in § 416.1124(c)(12) of this chapter which has not been excluded from your combined unearned income (or the combined unearned income of you and your living-with spouse);
(5) Earned income you use to pay impairment-related work expenses described in § 416.976 of this chapter, if you are receiving a social security disability insurance benefit, your disabling condition(s) does not include blindness and you are under age 65. We consider that you attain age 65 on the day before your 65th birthday. In lieu of determining the actual amount of these expenses, we will assume that the value of these work expenses is equal to a standard percentage of your total earned income per month if you tell us that you have impairment-related work expenses. The amount we exclude will be equal to the average percentage of gross earnings excluded for SSI recipients who have such expenses. Initially, the exclusion for impairment-related work expenses will be 16.3 percent of the gross earnings. We may adjust the percentages if the average percentage of gross earnings excluded for supplemental security income (SSI) recipients changes. If we make such a change we will publish a notice in the Federal Register . If excluding impairment-related work expenses greater than the standard percentage of your earned income would affect your eligibility or subsidy amount, you may establish that your actual expenses are greater than the standard percentage of your total earned income. You may do so by contacting us and providing evidence of your actual expenses. The exclusion of impairment-related work expenses also applies to the earnings of your living-with spouse if he or she is receiving a social security disability insurance benefit, the disabling condition(s) does not include blindness and he or she is under age 65;
(7) Earned income as described in § 416.1112(c)(8) of this chapter that you use to meet any expenses reasonably attributable to the earning of the income if you receive a social security disability insurance benefit based on blindness and you are under age 65. We consider that you attain age 65 on the day before your 65th birthday. In lieu of determining the actual amount of these expenses, we will assume that the value of these expenses is equal to a standard percentage of your total earned income per month. The amount we exclude will be equal to the average percentage of gross earnings excluded for SSI recipients who have such expenses. Initially, the exclusion for blind work expenses will be 25 percent of the gross earnings. We may adjust the percentages if the average percentage of gross earnings excluded for SSI recipients changes. If we make such a change we will publish a notice in the Federal Register . If excluding work expenses greater than the standard percentage of your earned income would affect your eligibility or subsidy amount, you may establish that your actual expenses are greater than the standard percentage of your earned income. You may do so by contacting us and providing evidence of your actual expenses. The exclusion of work expenses also applies to the earnings of your living-with spouse if he or she receives a social security disability insurance benefit based on blindness and is under age 65.
(a) Some of the types of unearned income we count are described in § 416.1121(a) through (g) of this chapter.
(b) We also count in-kind support and maintenance as unearned income. In-kind support and maintenance is any food and shelter that is given to you or that you receive because someone else pays for it (see § 418.3345).
(b) The maximum amount of income we count from in-kind support and maintenance during a month is limited to one-third of the monthly SSI Federal benefit rate for an eligible individual (as described in § 416.410 of this chapter) that is in effect for the period for which you are applying or are eligible for a subsidy. If you are married and living with your spouse, the maximum amount of income you and your spouse receive from in-kind support and maintenance during a month is limited to one-third of the monthly SSI Federal benefit rate for an eligible couple (as described in § 416.412 of this chapter). If the current market value of the in-kind support and maintenance you receive is less than one-third of the applicable monthly SSI Federal benefit rate, we count only the current market value as income.
(b) We do not count as income the unearned income described in § 416.1124(b), (c)(1) through (c)(12), and (c)(14) through (c)(21) of this chapter.
§ 418.3405 What types of resources do we count?
(a) We count liquid resources. Liquid resources are cash, financial accounts, and other financial instruments which can be converted to cash within 20 workdays, excluding certain nonworkdays as explained in § 416.120(d) of this chapter. Examples of resources that are ordinarily liquid are stocks, bonds, mutual fund shares, promissory notes, mortgages, life insurance policies, financial institution accounts (including savings, checking, and time deposits, also known as certificates of deposit), retirement accounts (such as individual retirement accounts (IRA), 401(k) accounts), trusts if they are revocable, funds in an irrevocable trust if the trust beneficiary can direct the use of the funds, and similar items. We will presume that these types of resources can be converted to cash within 20 workdays and are countable as resources for subsidy determinations. However, if the individual establishes that a particular resource cannot be converted to cash within 20 workdays, we will not count it as a resource.
(a) We count your resources. We count the resources of both you and your spouse regardless of whether one or both of you apply or are eligible for the subsidy if you are married and live with your spouse as of the month for which we determine your eligibility based on an application for a subsidy, as of the month for which we redetermine your eligibility for a subsidy as described in § 418.3125, or as of the month for which we determine your eligibility due to a change you reported as described in § 418.3120.
(b) We will determine your eligibility based on your resources alone if you are not married or if you are married but you are separated from your spouse at the time you apply for a subsidy or at the time we redetermine your eligibility for a subsidy as described in § 418.3125.
(c) If your subsidy is based on the resources of you and your spouse and we redetermine your subsidy as described in § 418.3120(b)(1), we will stop counting the resources of your spouse in the month following the month that we receive a report that your marriage ended due to death, divorce, or annulment; or a report that you and your spouse stopped living together.
(d) If your subsidy is based on the resources of you and your spouse, we will continue counting the resources of both you and your spouse if one of you is temporarily away from home as described in § 404.347 of this chapter.
(b) Non-liquid resources, other than nonhome real property. Non-liquid resources are resources that are not liquid resources as defined in § 418.3405. Irrevocable burial trusts and the irrevocable portion of prepaid burial contracts are considered non-liquid resources;
(c) Property of a trade or business which is essential to the means of self-support as provided in § 416.1222 of this chapter;
(d) Nonbusiness property which is essential to the means of self-support as provided in § 416.1224 of this chapter;
(e) Stock in regional or village corporations held by natives of Alaska during the twenty-year period in which the stock is inalienable pursuant to the Alaska Native Claims Settlement Act (see § 416.1228 of this chapter);
(f) Life insurance owned by an individual (and spouse, if any) to the extent provided in § 416.1230 of this chapter;
(g) Restricted allotted Indian lands as provided in § 416.1234 of this chapter;
(i) Disaster relief assistance as provided in § 416.1237 of this chapter;
(k) Burial spaces, as provided in § 416.1231(a) of this chapter;
(l) Title XVI or title II retroactive payments as provided in § 416.1233 of this chapter;
(m) Housing assistance as provided in § 416.1238 of this chapter;
(n) Refunds of Federal income taxes and advances made by an employer relating to an earned income tax credit, as provided in § 416.1235 of this chapter;
(o) Payments received as compensation incurred or losses suffered as a result of a crime, as provided in § 416.1229 of this chapter;
(p) Relocation assistance from a State or local government, as provided in § 416.1239 of this chapter;
(q) Dedicated financial institution accounts as provided in § 416.1247 of this chapter;
(s) Funds received and conserved to pay for medical and/or social services as provided in § 416.1103 of this chapter.
§ 418.3505 How would an increase, reduction or termination affect you?
§ 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.
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.
After you request review of our initial determination, we will review the information that we considered in making the initial determination and any other information we receive. We will make our decision based on this information. The issues that we will review are the issues with which you disagree. We may consider other issues, but we will provide you with advance notice of these other issues as explained in § 418.3625. If you are dissatisfied with our final decision, you may file an action in Federal district court.
§ 418.3675 How does our decision affect you?
If we become aware within 60 days of the date of our initial determination or our decision following a case review or telephone hearing, that a clerical error was made in determining whether or not you are eligible for a subsidy (either in whole or in part), we may issue a revised initial determination which would be effective back to the date you originally filed your application or the effective date of a subsidy changing event, provided you meet the requirements in § 418.3101. We may revise an initial determination or decision regardless of whether such revised determination or decision is favorable or unfavorable to you. If the revised determination or decision (which is a new initial determination) is not favorable to you, you will not be responsible for paying back any subsidy received prior to the revised determination or decision. We will mail you a notice of the revised determination which will explain to you that we have made a revised determination and that this determination replaces an earlier determination, how this determination affects your subsidy eligibility, and your right to request a hearing.