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 the parentheses of question #3 on
page 1 of the form.
Current
language:
Medicare Number (this number is printed on your Medicare
Card.)
Revised
language:
Medicare Number (the number is printed on your Medicare
card).
Justification
#1:
We are changing the wording to ensure proper structure.
Change # 2: We are placing parentheses on page 1, question #8, box 1 of the form.
Current
language: YES
Send
the additional information with this form to the address shown on the
bottom of page 2.
Revised
language: YES
(Send
the additional information with this form to the address shown on the
bottom of page 2).
Justification
#2:
We are adding the parentheses to improve clarity.
Change #3: We are placing parentheses on page 1, question #9, box 1 on the form.
Current language: YES You will receive a notice with the date and time of the hearing. Please complete questions 10 through 13.
Revised
language: YES
(You will receive a notice with the date and time of the hearing.
Please complete questions 10 through 13).
Justification
#3:
We are adding the parentheses to improve clarity.
Change #4: We are placing parentheses on page 1, question #9, box 2 on the form.
Current language: NO You will receive a decision based on the information available and any additional information you provide.
Revised
language: NO
(You
will receive a decision based on the information available and any
additional information you provide).
Justification
#4:
We are adding the parentheses to improve clarity.
Change #5: We are removing the word “must” in the statement on page 2, question #10 of the form.
Current language: To give you time to prepare for the hearing, we must allow at least 20 days between the date of your request and the date we schedule the hearing. Do you want a hearing sooner if scheduling permits?
Revised
language:
To
give you time to prepare for the hearing, we allow at least 20 days
between the date of your request and the date we schedule the
hearing. Do you want a hearing sooner if scheduling
permits?
Justification
#5:
We are removing the word “must” to improve clarity.
Change #6: We are changing some wording in instruction on page 2, question #13 of the form.
Current language: YES We call this a conference call. When we send you the notice scheduling the hearing, we will give you a telephone number to use for this conference call and additional instructions for setting up this call.
Revised
language: YES
We call this a conference call. We will send you a notice with: the
hearing date, time, conference call telephone number, and
instructions for setting up the conference call.
Justification
#6:
We are changing the wording to improve clarity.
Change #7: We are updating the URL to the SSA website in the Privacy Act
Statement
language.
Current
language: Additional
information about this and other system of records notices and our
programs are available from our Internet website at
www.socialsecurity.gov or at your local Social Security
office.
Revised
language: Additional
information about this and other system of records notices and our
programs are available from our Internet website at www.ssa.gov
or
at your local Social Security office.
Justification
#7:
We made this change to the URL to meet current agency messaging
standards.
Change
#8: We
are updating the edition date shown on the bottom of each
page.
Justification
#8:
We are updating the edition date following OMB approval.
Change #9: We are revising the Privacy Act Statements on this collection.
Justification #9: 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 Statements on this collection.
SSA-1021-INSTRUCTIONS
Change
#1:
We are changing the wording in instruction #6 on page 1 of the
form.
Current
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.
Revised
language:
If
you are married and live with your spouse, print your spouse's
Medicare number, if applicable, as it appears on your spouse's
Medicare card.
Justification
#1:
We
are changing the wording to improve clarity.
Change
#2:
We are changing the wording in instruction #9 on page 1 of the
form.
Current
language:
Check
"YES" if you want a hearing by telephone. Check "NO"
if you do not want a hearing by telephone. If you do not want a
hearing we will make a decision based on the information we have
available and any additional information you provide. We call this a
case review.
Revised
language:
Our hearings are conducted by telephone. Check
"YES" if you want a hearing or check "NO" if you
do not want a hearing. If you do not want a hearing, we will make a
decision based on the information we have available and any
additional information you provide. We call this a case
review.
Justification
2:
We
are changing the wording to improve clarity.
Change
#3:
We are changing the wording on page 2, instruction #10 of the
form.
Current
language:
We must allow at least 20 days from the date we receive your appeal
request and the date we schedule the hearing to give you time to
prepare. If you want a hearing sooner, check "YES".
Check "NO" if you want us to schedule the hearing at least
20 days from the date we receive your appeal request.
Revised
language:
We allow at least 20 days from the date we receive your appeal
request and the date we schedule the hearing to give you time to
prepare. If you want a hearing sooner, check "YES".
Check "NO" if you want us to schedule the hearing at least
20 days from the date we receive your appeal request.
Justification
#3:
We
are changing the wording to improve clarity.
Change #4: We are changing the wording on page 2, instruction #13 of the form.
Current
language:
Check
"YES" if you will have people other than yourself on the
telephone conversation. Check "NO" if you will not have
any other people at the hearing by the telephone. If "YES",
will you and the other people need to talk to us from more than one
telephone number? Check "YES" if you will have people
calling in from a telephone number different from yours. Otherwise,
check "NO".
Revised
language:
Check
"YES" if you will have people other than yourself at the
telephone hearing. Check "NO" if you will not have other
people at the telephone hearing. If "YES", will you and
the other people need to talk to us from more than one telephone
number? Check "YES" if you will have people calling in
from a telephone number different from yours. Otherwise, check
"NO".
Justification
#4:
We are changing the wording to improve clarity.
Change
#5:
We are updating
the edition date shown on the bottom of each page.
Justification
#5:
We are updating the edition date following 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 | 2024-07-25 |