Form i1020 Internet Application for Extra Help with Medicare Prescr
Application for Help with Medicare Prescription Drug Plan Costs
i1020 screens]
Internet Application for Help with Medicare Prescription Drug Plan Costs
OMB: 0960-0696
0960-0696
i1020
Screen Shots
Table of Contents
1. Pages Error! Bookmark not defined.
1.3. Should You Use This Application? 14
1.6. You Are Not Eligible For The Extra Help 17
1.8. Preparing To Find Out If You Qualify 19
1.9. Preparing To Use This Application 20
1.11. About You and Your Spouse 21
1.12. About You and Your Spouse - With 22
1.14. About the Person Completing 24
1.15. About the Person Completing 25
1.16. Reentry Number Issued Normal Process 26
1.17. About You And Your Spouse's Living Situation - Married 27
1.18. About Your Living Situation - Single 28
1.19. Wages And Earnings - Married 29
1.20. Wages And Earnings - Married 30
1.21. Wages And Earnings - Single (WITHOUT) 31
1.22. Wages And Earnings - Single (WITH) 32
1.23. Income Other Than Wages And Earnings - Married 33
1.24. Income Other Than Wages And Earnings - Single 34
1.27. Tool: Add Up Your Accounts 37
1.28. Tool: Add Up Your Investments 38
1.29. Tool: Add Up Your Other Pensions And Annuities 39
1.30. Tool: Add Up Your Types Of Income 40
1.31. (Find Out if You Qualify) 41
1.32. Find Out If You And Your Spouse Qualify (Married) Part 1 (WITHOUT) 42
1.33. Find Out If You And Your Spouse Qualify (Married) Part 1 (WITH) 43
1.34. Find Out If You Qualify (Single) Part 1 44
1.35. Find Out If You Qualify (Married) Part 3 (WITH) 45
1.36. Find Out If You Qualify (Single) Part 3 (WITHOUT) 46
1.37. Find Out if You Qualify (Single) Part 3 (WITH) 47
1.38. Find Out If You Qualify (Married) Part 2 48
1.39. Find Out If You Qualify (Single) Part 2 49
1.40. Find Out If You Qualify (You Should Apply) 50
1.41. Find Out If You Qualify (You Probably Do Not Qualify) 51
1.43. Review Your Information 53
1.44. Review Your Information 54
1.51. Successful Submission - Print Or Save Your Receipt 61
1.52. Unsuccessful Submission 62
1.54. Missing Information (Fix Errors) 64
1.55. Successful Submission - Print Or Save Yoour Receipt (print) 65
1.56. Unsuccessful Submission 66
1.58. Authentication - Medicare Part D Database Not Eligible Or SSI Recipient 68
1.59. Check The Social Security Number You Entered 69
1.60. How The Online Application Works 70
1.61. Privacy Act Statement 71
1.62. Internet Security Policy 72
1.63. Limit Number Of Restarts 73
1.64. Limit Number Of Starts For A New Application 74
1.65. Limit On The Number Of Tries To Start An Application 75
1.67. Not Eligible For The Prescription Drug Plan 77
1.70. Paperwork Reduction Act Statement 80
1.71. Print/Save/View Guide 81
1.74. Special Instructions For Blind Users 84
1.76. There Is A Pending Application For This Social Security Number 86
1.77. Warning System Shutdown 87
1.78. We Cannot Process Your Request 88
1.80. You Do Not Live In One Of The 50 States Or DC 90
1.81. You Have Already Sent Us An Application 91
1.82. Your Session Has Expired 92
1.87. Help: Do you (or your spouse, if married and living together) have Medicare? 97
1.89. Help: Have you (or your spouse, if married and living together) received: 99
1.90. Help: In which state do you (or your spouse, if married and living together) live? 100
1.91. Help: What is your marital status? 101
1.92. Help: Do you have combined savings, investments, and real estate worth more than: 102
1.93. Help: Have you worked in 2010 or 2011? 103
1.94. Help: Has your spouse worked in 2010 or 2011? 104
1.95. Help: Have you worked this calendar year? 105
1.96. Help: Has your spouse worked this calendar year? 106
1.97. Help: Are you UNDER age 65? 107
1.98. Help: Is your spouse UNDER age 65? 108
1.99. Help: Not counting your spouse, how many other relatives live in your household? 109
1.102. Help: Does your spouse have to pay for things that enable him or her to work? 112
1.103. Help: Do you expect to earn wages this calendar year? 113
1.104. Help: Does your spouse expect to earn wages this calendar year? 114
1.105. Help: What do you expect your net earnings from self-employment to be this calendar year? 115
1.107. Help: Have you stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012? 117
1.109. Help: Do you receive Social Security benefits? 119
1.110. Help: Does your spouse receive Social Security benefits? 120
1.111. Help: Do you receive Railroad Retirement benefits? 121
1.112. Help: Does your spouse receive Railroad Retirement benefits? 122
1.113. Help: Do you receive Veterans benefits? 123
1.114. Help: Does your spouse receive Veterans benefits? 124
1.115. Help: Do you receive income from other pensions or annuities? 125
1.116. Help: Does your spouse receive income from other pensions or annuities? 126
1.120. Help: Your Social Security Number 130
1.121. Help: What is your date of birth? 131
1.122. Help: Spouse's Name 132
1.123. Help: Spouse's Social Security Number 133
1.124. Help: What is your spouse's date of birth? 134
1.125. Help: Your Mailing Address 135
1.126. Help: Your Phone Number 136
1.128. Help: Do you have combined savings, investments, and real estate worth more than $25,260? 138
1.129. Help: OPTIONAL: (contact person) 139
1.130. Help: Contact's Phone Number 140
1.131. Help: Do you have combined savings, investments, and real estate worth more than $12,640? 141
1.132. Help: Relationship to Applicant 142
1.133. Help: Form Completer's Phone Number 143
1.134. Help: Form Completer's Address 144
1.135. Help: Primary Applicant's Name 145
1.136. Help: Primary Applicant's Social Security Number 146
1.137. Help: What is the primary applicant's date of birth? 147
1.138. Help: Has the primary applicant worked in 2010 or 2011? 148
1.141. Help: Spouse's Name 151
1.142. Help: Spouse's Security Number 152
1.143. Help: What is the spouse's date of birth? 153
1.144. Help: Has the applicant's spouse worked in 2010 or 2011? 154
1.145. Help: Mailing Address 155
1.147. Help: Applicant's Name 157
1.148. Help: Applicant's Social Security Number 158
1.149. Help: What is the applicant's date of birth? 159
1.150. Help: Has the applicant worked in 2010 or 2011? 160
1.152. Help: Have these wages or self-employment earnings decreased in the last two years? 162
1.153. Help: Have these wages or self-employment earnings decreased in the last two years? 163
1.154. Help: Has any of the income from these sources decreased in the last two years? 164
1.155. Help: Has any of the income from these sources decreased in the last two years? 165
1.158. Help: Do you or your spouse have any other cash at home or anywhere else? 168
1.159. Help: Do you have bank accounts (checkings, savings and certificates of deposit)? 169
1.161. Help: Do you have any other cash at home or anywhere else? 171
Explanation of Changes
Revision to the Collection Instrument
Change 1: We added “life insurance” to the list of assets in the “self screener” resource question. We do not count life insurance as a resource. We also simplified the question by changing “the home you live in” to “your home.” We are changing the question from:
If you are married and living with your spouse, do you have savings, investments or real estate worth more than $25,260? If you are not married or you do not live with your spouse, is the value more than $12,640? Do NOT count the home you live in, vehicles, personal possessions, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.
to:
If you are married and live with your spouse, do you have savings, investments or real estate worth more than $25,260? If you are not married or you do not live with your spouse, is the value more than $12,640? Do NOT count your home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.
Justification 1:
Effective January 1, 2010, we no longer count the value of any life insurance policy as a resource for Extra Help. We also streamlined the wording in the question so that “life insurance” would not affect optical sensor formatting when we translate to Spanish. Finally, we simplified language regarding the applicant’s home.
Change 2: We are adding the word “unemployment” to the “Other income” category. We are changing the question from:
Other income not listed above, including alimony, net rental income, workers compensation, private or state disability payments, etc. (Specify):_______
to:
Other income not listed above, including alimony, net rental income, workers compensation, unemployment, private or state disability payments, etc. (Specify):_______
Justification 2: SSA’s Office of Quality Performance conducted a Low Income Subsidy Awards review and found that a number of application errors are due to unreported unemployment income. We revised the language in an effort to reduce these errors.
Change 3: We are changing the years in wage and self- employment questions to reflect the form’s renewal date.
If you or your spouse, stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012, enter the month and year:
to:
If you or your spouse, stopped working in 2011 or 2012, or plan to stop working in 2012 or 2013, enter the month and year:
Justification 3: We are renewing the form for use beginning in February 2012, so we would like to update the years in which we ask about changes in income as well as the example for ease of use by the public.
A.2. Welcome
We
corrected the SHIP acronym to State Health Insurance Counseling
and Assistance Program. We
capitalized each occurrence of the letter “S” in the
word state.
Welcome
We
corrected the SHIP acronym to State Health Insurance Counseling
and Assistance Program. We
capitalized each occurrence of the letter “S” in the
word state.
Should You Use This Application?
We
added “life insurance” to the list of assets that we
do not count
We
simplified language regarding the applicant’s home.
Welcome Back
Save & Exit
A.6.1. User Interface
You Are Not Eligible For The Extra Help
A.7.1. User Interface
A.8. Go Ahead
A.8.1. User Interface
A.9. Preparing To Find Out If You Qualify
A.9.1. User Interface
Preparing To Use This Application
A.10.1. User Interface
(Apply Now)
A.11. About You and Your Spouse
A.11.1. User Interface
A.12. About You and Your Spouse - With
A.12.1. User Interface
About You
A.13.1. User Interface
About the Person Completing
A.14.1. User Interface
A.15. About the Person Completing
Reentry Number Issued Normal Process
A.16. About You And Your Spouse's Living Situation - Married
A
A.18. Wages And Earnings - Married
We
updated the years “2010 or 2011” to “2011 or
2012.” We
updated the years “2011 or 2012” to “2012 or
2013.”
Wages And Earnings - Married
We
updated the years “2010 or 2011” to “2011 or
2012.” We
updated the years “2011 or 2012” to “2012 or
2013”.
Wages And Earnings - Single (WITHOUT)
We
updated the years “2010 or 2011” to “2011 or
2012.” We
updated the years “2011 or 2012” to “2012 or
2013.”
Wages And Earnings - Single (WITH)
We
updated the years “2010 or 2011” to “2011 or
2012.” We
updated the years “2011 or 2012” to “2012 or
2013.”
Income Other Than Wages And Earnings - Married
We changed
the “Other Income” question from:
“Other income not listed above, including alimony, net
rental income, worker’s compensation, private or state
disability payments, etc. (Specify):_____ to:
“Other income not listed above, including alimony, net
rental income, worker’s compensation, unemployment, private
or State disability payments, etc. (Specify):_____
A.23. Income Other Than Wages And Earnings - Single
“Other income not listed above, including alimony, net rental income, worker’s compensation, private or state disability payments, etc. (Specify):_____ to: “Other income not listed above, including alimony, net rental income, worker’s compensation, unemployment, private or State disability payments, etc. (Specify):_____
|
A.27. Tool: Add Up Your Investments
A.28. Tool: Add Up Your Other Pensions And Annuities
A.29. Tool: Add Up Your Types Of Income
-
We changed the “Other Income” question from:
“Other income not listed above, including alimony, net rental income, worker’s compensation, private or state disability payments, etc. (Specify):_____
to:
“Other income not listed above, including alimony, net rental income, worker’s compensation, unemployment, private or State disability payments, etc. (Specify):_____
A.30. (Find Out if You Qualify)
A.31. Find Out If You And Your Spouse Qualify (Married) Part 1 (WITHOUT)
F
A
A.34. Find Out If You Qualify (Married) Part 3 (WITH)
We
changed the years “2010 or 2011” to “2011 or
2012.”
We
changed the years “2011 or 2012” to “2012 or
2013.”
Find Out If You Qualify (Single) Part 3 (WITHOUT)
We
changed the years “2010 or 2011” to “2011 or
2012.”
We
changed the years “2011 or 2012” to “2012 or
2013.”
Find Out if You Qualify (Single) Part 3 (WITH)
We
changed the years “2010 or 2011” to “2011 or
2012.”
We
changed the years “2011 or 2012” to “2012 or
2013.”
Find Out If You Qualify (Married) Part 2
-
We changed the “Other Income” question from:
“Other income not listed above, including alimony, net rental income, worker’s compensation, private or state disability payments, etc. (Specify):_____
to:
“Other income not listed above, including alimony, net rental income, worker’s compensation, unemployment, private or State disability payments, etc. (Specify):_____
A.38. Find Out If You Qualify (Single) Part 2
“Other income not listed above, including alimony, net rental income, worker’s compensation, private or state disability payments, etc. (Specify):_____ to: “Other income not listed above, including alimony, net rental income, worker’s compensation, unemployment, private or State disability payments, etc. (Specify):_____
|
A.39. Find Out If You Qualify (You Should Apply)
A.40. Find Out If You Qualify (You Probably Do Not Qualify)
Ready to Submit
Ready to Submit
Ready to Submit
Ready to Submit
Ready to Submit
Successful Submission - Print Or Save Your Receipt
A.53. Missing Information (Fix Errors)
A.54. Successful Submission - Print Or Save Yoour Receipt (print)
“Please Confirm”
message pages have been removed as they are no longer required with
the navigational changes.
Authentication - Medicare Part D Database Not Eligible Or SSI Recipient
A.57. Check The Social Security Number You Entered
A.58. How The Online Application Works
A.61. Limit Number Of Starts For A New Application
A.62. Limit On The Number Of Tries To Start An Application
A.64. Not Eligible For The Prescription Drug Plan
A.67. Paperwork Reduction Act Statement
Sign-In Problem
A.71. Special Instructions For Blind Users
A.73. There Is A Pending Application For This Social Security Number
A.75. We Cannot Process Your Request
A.77. You Do Not Live In One Of The 50 States Or DC
A.78. You Have Already Sent Us An Application
A.79. Your Session Has Expired
A
Help: Are you assisting someone (other than your spouse who lives with you) with this application?
A.83. Help: Did you (or your spouse, if married and living together) get an application in the mail from us?
A.84. Help: Do you (or your spouse, if married and living together) have Medicare?
A.85. Help: Are you (or your spouse, if married and living together) 64 years and 9 months old or older?
A.86. Help: Have you (or your spouse, if married and living together) received:
Help: In which state do you (or your spouse, if married and living together) live?
A.88. Help: What is your marital status?
A.89. Help: Do you have combined savings, investments, and real estate worth more than:
A.90. Help: Have you worked in 2010 or 2011?
We
updated the years “2010 or 2011” to “2011 or
2012.”
Help: Has your spouse worked in 2010 or 2011?
We
updated the years “2010 or 2011” to “2011 or
2012.”
Help: Have you worked this calendar year?
A.93. Help: Has your spouse worked this calendar year?
A.94. Help: Are you UNDER age 65?
A.95. Help: Is your spouse UNDER age 65?
A.96. Help: Not counting your spouse, how many other relatives live in your household?
A.97. Help: How many relatives live in your household and receive at least one-half of their financial support from you?
A.98. Help: Do you have to pay for things related to a disability or blindness that enable you to work?
Help: Does your spouse have to pay for things that enable him or her to work?
A.100. Help: Do you expect to earn wages this calendar year?
A.101. Help: Does your spouse expect to earn wages this calendar year?
Help: What do you expect your net earnings from self-employment to be this calendar year?
Help: What does your spouse expect the net earnings from self-employment to be this calendar year?
Help: Have you stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012?
-
We updated the years “2010 or 2011” to “2011 or 2012.”
We updated the years “2011 or 2012” to “2012 or 2013.”
Help: Has you your spouse stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012?
We
updated the years “2010 or 2011” to “2011 or
2012.” We
updated the years “2011 or 2012” to “2012 or
2013.”
Help: Do you receive Social Security benefits?
Help: Does your spouse receive Social Security benefits?
Help: Do you receive Railroad Retirement benefits?
Help: Does your spouse receive Railroad Retirement benefits?
Help: Do you receive Veterans benefits?
A110. Help: Does your spouse receive Veterans benefits?
Help: Do you receive income from other pensions or annuities?
Help: Does your spouse receive income from other pensions or annuities?
Help: Do you receive other income not listed above, including alimony, net rental income, workers' compensation, etc.?
We changed
the “Other Income” question from:
“Other income not listed above, including alimony, net
rental income, worker’s compensation, private or state
disability payments, etc. (Specify):_____ to:
“Other income not listed above, including alimony, net
rental income, worker’s compensation, unemployment, private
or State disability payments, etc. (Specify):_____
A.114. Help: Does your spouse receive other income not listed above, including alimony, net rental income, workers' compensation, etc.?
We changed
the “Other Income” question from:
“Other income not listed above, including alimony, net
rental income, worker’s compensation, private or state
disability payments, etc. (Specify):_____ to:
“Other income not listed above, including alimony, net
rental income, worker’s compensation, unemployment, private
or State disability payments, etc. (Specify):_____
Help: Your Name
A.116. Help: Your Social Security Number
A.117. Help: What is your date of birth?
A.119. Help: Spouse's Social Security Number
A.120. Help: What is your spouse's date of birth?
A.121. Help: Your Mailing Address
A.122. Help: Your Phone Number
A.123. Help: If your spouse has Medicare (or expects to have it in the next three months), does he or she also wish to apply?
A.124. Help: Do you have combined savings, investments, and real estate worth more than $25,260?
A.125. Help: OPTIONAL: (contact person)
A.126. Help: Contact's Phone Number
A.127. Help: Do you have combined savings, investments, and real estate worth more than $12,640?
A.128. Help: Relationship to Applicant
A.129. Help: Form Completer's Phone Number
A.130. Help: Form Completer's Address
A.131. Help: Primary Applicant's Name
A.132. Help: Primary Applicant's Social Security Number
A.133. Help: What is the primary applicant's date of birth?
A.134. Help: Has the primary applicant worked in 2010 or 2011?
|
A.135. Help: If the spouse has Medicare (or expects to have it in the next three months), does he or she also wish to apply?
A.136. Help: Do the applicants have combined savings, investments, and real estate worth more than $25,260?
A.138. Help: Spouse's Security Number
A.139. Help: What is the spouse's date of birth?
A.140. Help: Has the applicant's spouse worked in 2010 or 2011?
|
A.144. Help: Applicant's Social Security Number
A.145. Help: What is the applicant's date of birth?
A.146. Help: Has the applicant worked in 2010 or 2011?
-
We updated the years “2010 or 2011” to “2011 or 2012.”
A.147. Help: Does the applicant have combined savings, investments, and real estate worth more than $12,640?
A.148. Help: Have these wages or self-employment earnings decreased in the last two years?
A.149. Help: Have these wages or self-employment earnings decreased in the last two years?
A.150. Help: Has any of the income from these sources decreased in the last two years?
A.151. Help: Has any of the income from these sources decreased in the last two years?
A.152. Help: Do you or your spouse have bank accounts (checkings, savings and certificates of deposit)?
Help: Do you or your spouse have stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments?
A.154. Help: Do you or your spouse have any other cash at home or anywhere else?
Help: Do you have bank accounts (checkings, savings and certificates of deposit)?
Help: Do you have stocks, bonds, savings bonds, mutual funds, Individual Retirement Accounts or other similar investments?
Help: Do you have any other cash at home or anywhere else?
Help: Will some money from any of the sources listed above be used to pay for your funeral or burial expenses?
A.159. Help: Will some money from any of the sources listed above be used to pay for your spouse's funeral or burial expenses?
A.160. Help: Other than your home and the property on which it is located, do you or your spouse own any real estate?
A.161. Help: Other than your home and the property on which it is located, do you own any real estate?
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Fujitsu |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |
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