Appeal of Determination for Extra Help with Medicare Prescription Drug Costs
Form SSA-1021
OMB No. 0960-0695
Revision to the Collection Instrument
SSA-1021
Change #1: We are changing the wording in question #3 on page 1 of the form.
Current language: Medicare Number (if different from Social Security number):
Revised language: Medicare Number (this number is printed on your Medicare Card):
Justification #1: The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 legislation mandates the removal of the SSN-based Health Insurance Claim Number (HICN) from all Medicare cards. CMS replaced the SSN-based HICN with a new randomized 11 digit alpha numeric Medicare Beneficiary Identifier (MBI). We are requesting to align with the MACRA mandate by updating applicant instructions for entering the new MBI on SSA-1021 paper application forms.
Change 2: We are changing the wording in question #6 on page 1 of the form.
Current language: Spouse's Medicare Number (if different from spouse's Social Security number and spouse lives at same address as you):
Revised language: Spouse’s Medicare Number (if spouse lives at same address as you):
Justification #2: The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 legislation mandates the removal of the SSN-based Health Insurance Claim Number (HICN) from all Medicare cards. CMS replaced the SSN-based HICN with a new randomized 11 digit alpha numeric Medicare Beneficiary Identifier (MBI). We are requesting to align with the MACRA mandate by updating applicant instructions for entering the spouse’s new MBI on SSA-1021 paper application forms.
Change #3: We are updating the year shown on the bottom of each page.
Justification# 3: We made this change to update the edition date after OMB approval.
SSA-1021-INST
Change #4: We are changing the wording in instruction #1 on page 1 of the form.
Current language: Print name as it appears on your Social Security card.
Revised language: Print your name as it appears on your Social Security card.
Justification #4: We made this change to improve clarity.
Change #5: We are changing the wording in instruction #2 on page 1 of the form.
Current language: Print Social Security number as it appears on your Social Security card.
Revised language: Print your Social Security number as it appears on your Social Security card.
Justification 2: We made this change to improve clarity.
Change #6: We are changing the wording in instruction #3 on page 1 of the form.
Current language: Complete only if your Medicare number is different from your Social Security number.
Revised language: Print your Medicare number as it appears on your Medicare card.
Justification #6: We made this change to improve clarity and to align this instruction with legislative mandates under The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.
Change #7: We are changing the wording in instruction #4 on page 1 of the form.
Current language: Print name as it appears on your spouse's Social Security card. Complete only if your spouse lives at the same address.
Revised language: If you are not married or you do not live with your spouse, go to question 7. If you live with your spouse, print your spouse's name as it appears on your spouse's Social Security Card.
Justification #7: We made this change to improve clarity.
Change #8: We are changing the wording in instruction #5 on page 1 of the form.
Current language: Print Social Security number as it appears on your spouse’s Social Security card. Complete only if your spouse lives at the same address.
Revised language: If you married and live with your spouse, print your spouse's name as it appears on your spouse's Social Security Card.
Justification #8: We made this change to improve clarity.
Change#9: We are changing the wording in instruction #6 on page 1 of the form.
Current language: Complete only if your spouse lives at the same address and his or her Medicare number is different from his or her Social Security number.
Revised language: If you are married and live with your spouse, print your spouse's Medicare number as it appears on your spouse's Medicare card.
Justification #9: We made this change to improve clarity.
Change #10: We are changing the wording in instruction #7 on page 1 of the form.
Current language: Briefly state the determination that you disagree with and why you disagree with that determination. You can add to this statement by attaching additional pages.
Revised language: Briefly tell us the decision you disagree with and why you disagree. You can add to this statement by attaching additional pages.
Justification #10: We made this change to improve clarity.
Change #11: We are placing parenthesis around the words “YES” and “NO” in instruction #9 on page 1 of the form.
Justification #11: We made this change to improve clarity.
Change #12: We are placing parenthesis around the words “YES” and “NO” in instruction #10 on page 2 of the form.
Justification#12: We made this change to improve clarity.
Change 13: We are placing parenthesis around the words “YES” and “NO” in instruction #11 on page 2 of the form.
Justification #13: We made this change to improve clarity.
Change #14: We are placing parenthesis around the words “YES” and “NO” in instruction #12 on page 2 of the form.
Justification #14: We made this change to improve clarity.
Change #15: We are placing parenthesis around the words “YES” and “NO” in instruction #13 on page 2 of the form.
Justification #15: We made this change to improve clarity.
Change #16: SSA updated the year shown on the bottom of each page.
Justification 16: We made this change to update the edition date after OMB approval.
We will implement these revisions upon OMB’s approval.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | OEEMP/Medicare |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |