Addendum to Supporting Statement 0960-0695

ADDENDUM TO THE SUPPORTING STATEMENT

FOR FORM SSA-1021

APPEAL OF DETERMINATION FOR HELP WITH

MEDICARE PRESCRIPTION DRUG PLAN COSTS

20 CFR 418.3110

OMB No. 0960-0695

Terms of Clearance

This ICR is approved without change. However, given the number of individuals who use this form annually, SSA shall seriously consider making this form available electronically. Upon next submission, SSA shall explain in more detail why this form has not been offered in electronic format, should SSA decide not to offer it electronically. That explanation should include the cost that would be associated with making it available electronically.

SSA Response

SSA employees use an internal electronic system, the Medicare Application Processing System (MAPS), for claimants who wish to file an appeal via an in-person or telephone interview. However, SSA is not considering an electronic expansion for this process due

to limited financial resources for systems development and low priority at this time. Since this form has relatively few respondents (75,000 which is only 25,000 above the GPEA cut-off of 50,000), and is a relatively short, simple form, developing an electronic version is not as urgent as for our more complicated initiatives.

Minor Revisions to the Collection Instrument

SSA is making the following revisions:

We are revising the PRA statement to reflect our current boilerplate language.  The current language, which dates back to the last reprint of the form, is now outdated.

SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the first page of the form.