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Federal forms, ICRs, and supporting documents

Information Collection Request

Application for Help with Medicare Prescription Drug Plan Costs

ICR 200907-0960-002 · OMB 0960-0696 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form SSA-1020 Application for Help with Medicare Prescription Drug Plan Costs (Paper Form) Form and Instruction Unchanged Available
Form i1020 Internet Application for Help with Medicare Prescription Drug Plan Costs Form and Instruction Unchanged Available
0960-0696 MSP letter.doc Supplementary Document Uploaded 2009-07-02 Repair queued
0960-0696 change sheet.doc Justification for No Material/Nonsubstantive Change Uploaded 2009-07-02 Available
IC Document Collections
IC IDCollectionTypeStatusForm
38067 Application for Help with Medicare Prescription Drug Plan Costs (Paper Form) Form and Instruction Unchanged
189790 MSP Follow-Up Letter for 2010 Other-MSP Follow-Up Letter New
187636 Application for Extra Help With Medicare Prescription Drug Plan Costs (field office interview) Other-Screens for SSA field office interview Unchanged
182917 Internet Application for Help with Medicare Prescription Drug Plan Costs Form and Instruction Unchanged
ICR Details
0960-0696 200907-0960-002
Historical Active 200812-0960-010
SSA
Application for Help with Medicare Prescription Drug Plan Costs
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 07/21/2009
Retrieve Notice of Action (NOA) 07/02/2009
  Inventory as of this Action Requested Previously Approved
02/29/2012 02/29/2012 02/29/2012
1,020,000 0 1,000,000
481,333 0 480,000
0 0 0
The Medicare Modernization Act of 2003 mandated the creation of the Medicare Part D prescription drug coverage program and provided for certain subsidies for eligible Medicare beneficiaries to help pay for the costs of prescription drugs. SSA uses Form SSA-1020 (and the i1020, its electronic counterpart), the Application for Extra Help with Medicare Prescription Drug Plan Costs, to collect information to make Part D subsidy eligibility determinations. In compliance with P.L. 110-275, beginning in January 2010, SSA will use a new version of Form SSA-1020. In this new version, SSA will eliminate questions about the value of life insurance policies and in-kind support and maintenance, and we will ask applicants about their interest in applying for the Medicare Savings Program. This information collection request (ICR) is for a non-substantive change we are making due to this legislation. Specifically, we are creating a letter and follow-up form to send to those applicants who erroneously submit the old, unrevised form SSA-1020 after the legislatively mandated changes become effective.
PL: Pub.L. 110 - 275 100 Name of Law: Medicare Improvements for Patients and Providers Act of 2008
   US Code: 42 USC 1395w-101 Name of Law: Social Security Act
  
PL: Pub.L. 110 - 275 100 Name of Law: Medicare Improvements for Patients and Providers Act of 2008
Not associated with rulemaking
  73 FR 64004 10/28/2008
73 FR 79537 12/29/2008
Yes
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1,020,000 1,000,000 20,000 0 0 0
Annual Time Burden (Hours) 481,333 480,000 1,333 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The burden is increasing slightly to account for the respondents who have erroneously submitted an old form SSA-1020 in 2010 and as a result will receive and respond to the MSP letter.
$3,812,150
No
No
Uncollected
Uncollected
No
Uncollected
John Biles 410 965-3758 [email protected]
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
07/02/2009