FORM SSA-1020 (APPLICATION FOR EXTRA HELP WITH MEDICARE PRESCRIPTION DRUG PLAN COSTS)
OMB No. 0960-0696
Justification for Non-Substantive Change
Background
In early 2009, SSA obtained OMB approval for changes to form SSA-1020. These changes were the result of legislative mandates in the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008. MIPPA required SSA to add a question to the SSA-1020 asking applicants if they are interested in filing for a Medicare Savings Program (MSP) through their state.
The MIPPA changes become effective January 1, 2010; however, as we transition to the new form, SSA expects to receive some outdated SSA-1020s throughout the year 2010. Applicants who request form SSA-1020 by mail are instructed to return it to the Wilkes-Barre Data Operations Center (WBDOC). In 2010, when the WBDOC receives outdated copies of form SSA-1020, it will send a letter to the applicants who submitted the outdated forms. This letter will include the MSP information found only on the new form.
Timeframe for mailing the MSP letter
SSA will mail the MSP letters beginning January 2010, and will continue to do so throughout the 2010 calendar year. Any applicant who completed an outdated SSA-1020 but submitted it on or after January 2010 will receive this letter from WBDOC requesting an answer to the MSP question.
Description of MSP Letter
First page:
First and second paragraphs state that SSA received an application for Extra Help and explains the new law changes that start in 2010. The MIPPA changes include:
SSA will no longer count in-kind support and maintenance as income,
SSA will no longer count the cash surrender value of life insurance policies as resources, and
With consent, SSA will send information to the state to begin the application process for help with Medicare cost-sharing (MSP question)
Third paragraph explains that completing the attached form and mailing it back in the preaddressed/stamped envelope within 20 days from the date of the letter to WBDOC will start the MSP application process.
Fourth paragraph explains how to obtain information on the MSP, Medicare Prescription Drug Plans or how to enroll in a plan. The paragraph also lists the Medicare website and the Medicare toll-free telephone number if the applicant needs additional information.
Second page:
Displays the Privacy Act/Paperwork Reduction Notice statements.
MSP Form Question Page
First paragraph is the statement “YES, I/we want to see if I/we qualify for a Medicare Savings Program.”
Second paragraph is the statement “NO, I do not want to see if I qualify for a Medicare Savings Program.”
Third paragraph instructs the applicant to place an ”X” in the Yes box if they want to apply for the MSP or an ”X” in the No box if they do not want to apply for the MSP.
Fourth paragraph explains that by checking the ”Yes” box, the applicant gives SSA permission to obtain and disclose information related to their income, resources, and assets both foreign and domestic consistent with privacy laws to the state medical assistance office for the purpose of qualifying for a Medicare Savings Program.
Fifth paragraph explains that by checking the “No” box, the applicant does not want SSA to disclose any information to the state medical assistance office for the purpose of starting a Medicare Savings Program application.
Sixth paragraph requires a signature and date for the applicant and spouse if applicable.
Seventh paragraph is a disclaimer statement to let the applicant know that if the form is not returned, no information will be sent to their state medical assistance office. Also if the applicant is married and living with the spouse, the spouse’s signature is required.
NOTE: Please note that OMB has already approved all of the above information when we re-cleared form SSA-1020 earlier this year. We are simply ensuring that those Medicare beneficiaries who do not have a new form will have a chance to answer the MSP questions.
Burden Information:
Number of respondents submitting old SSA-1020s: 20,000 (estimated).
Response time: 4 minutes (to answer the MSP question in response to the letter we send).
Burden: 1,333.33 hours.
0960-0696 (SSA-1020) non-substantive change
| File Type | application/msword |
| File Title | General Note: |
| Author | 055019 |
| Last Modified By | 666429 |
| File Modified | 2009-07-02 |
| File Created | 2009-07-02 |