Addendum to the Supporting Statement

Addendum to the Supporting Statement for Form SSA-44:

Medicare Part B Income-Related Premium Life-Changing Event Form

20 CFR 418.1205, .1255, and .1265

OMB No. 0960-0735

Below we describe the changes to form SSA-44.

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• Change 1: We changed the 6^th check block in Step 1 from “Loss of Income from Income-Producing Property” to “Loss of Income-Producing Property.”

  • Justification: We made this language change to minimize user confusion, redundancy, and to bring the language into conformity with the intent of regulation 20 CFR 418.1205 (definition and explanation of what constitutes a life-changing event).

• Change 2: We added a new check block in Step 1 entitled “Employer Settlement Payment”

  • Justification: We created a new life-changing event to be consistent with amended regulation section 20 CFR 418.1205 (definition and explanation of what constitutes a life-changing event).

Page 5

• Change 1: In Step 1, row 5, column 1 -- “Life-changing event,” we changed “Loss of Income from Income-Producing Property” to “Loss of Income-Producing Property.”

  • Justification: We made this change to be consistent with the Page 2 wording change (described on the first page of this document).

• Change 2: In Step 1, row 5, column 2 -- “Use this category if,” we changed the following language:

“You or your spouse experienced a loss of income from income-producing property, that was not at your direction (e.g., not due to the sale or transfer of the property). This includes loss of income from real property in a Presidentially- or Gubernatorially-declared disaster area, destruction of livestock or crops due to natural disaster or disease, or loss of income from property due to arson.”

to

“You or your spouse experienced a loss of income from income-producing property, that was not at your direction (e.g., not due to the sale or transfer of the property). This includes loss of income from real property in a Presidentially or Gubernatorially-declared disaster area, destruction of livestock or crops due to natural disaster or disease, or loss of income from property due to arson, or loss of investment property due to fraud or theft.”

• Justification: We made this language change to minimize user confusion and redundancy and to bring the language into conformity with the intent of regulation 20 CFR 418.1205 (definition and explanation of what constitutes a life-changing event).

• Change 3: In Step 1, row 6, column 2 -- “Use this category if,” we changed language from “You or your spouse experienced a reduction in or loss of certain forms of pension income due to termination or reorganization of the pension plan or a scheduled cessation of benefits” to “You or your spouse experienced a scheduled cessation, termination or reorganization of an employer’s pension plan.”

  • Justification: We made this language change to minimize user confusion and to bring the language into conformity with the intent of regulation section 20 CFR 418.1205 (definition and explanation of what constitutes a life-changing event).

• Change 4: In Step 1, row 7, column 1-- “Life-changing event,” we added new language “Employer Settlement Payment.”

  • Justification: The amended regulation 20 CFR 418.1205 (definition and explanation of what constitutes a life-changing event) will add this new life-changing event.

• Change 5: In Step 1, row 7, column 2-- “Use this category if,” we added new language that reads, “You or your spouse receive a settlement from an employer or former employer because of the employer’s bankruptcy or reorganization.”

  • Justification: This language explains the new life-changing event that will be added by amended regulation section 20 CFR 418.1205 (definition and explanation of what constitutes a life-changing event).

Page 8

• Change 1: In Step 4, row 5 column 1-- “Life-changing event,” we changed “Loss of Income from Income-Producing Property” to “Loss of Income-Producing Property.”

  • Justification: We made this change to be consistent with the Page 2 wording change (described on the first page of this document).

• Change 2: In Step 4, row 5 column 2 -- “Use this category if,” we changed from

“An original copy of an insurance company adjuster’s statement of loss or a letter from a State or Federal government about the uncompensated loss”

to

“An original copy of an insurance company adjuster’s statement of loss or a letter from a State or Federal government about the uncompensated loss. If the loss was due to investment fraud (theft), we also require proof of conviction for the theft, such as a court document citing theft or fraud relating to your or your spouse’s loss.”

• Justification: We made this language change to minimize user confusion and redundancy and to bring the language into conformity with the intent of regulation 20 CFR 418.1205 (definition and explanation of what constitutes a life-changing event).

• Change 3: In Step 4, row 6, column 2 -- “Use this category if,” we changed the language from “An original letter from the Pension Benefit Guaranty Corporation or your pension fund administrator” to “A letter or statement from your pension fund administrator that explains the reduction or termination of your benefits.”

  • Justification: We made this language change to minimize user confusion and bring the language into conformity with the intent of regulation 20 CFR 418.1205 (definition and explanation of what constitutes a life-changing event).

• Change 4: In Step 4, row 7, column 1 -- “Life-changing event,” we added new language “Employer Settlement.”

  • Justification: We created a new life-changing event to be consistent with amended regulation section 20 CFR 418.1205 (definition and explanation of what constitutes a life-changing event).

• Change 5: In Step 4, row 7, column 2 -- “Use this category if,” we added new language that reads, “A letter or statement the employer stating the settlement terms of the bankruptcy court and how it affects you or your spouse.”

  • Justification: We created a new life-changing event to be consistent with amended regulation section 20 CFR 418.1205 (definition and explanation of what constitutes a life-changing event).

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