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Federal forms, ICRs, and supporting documents

Information Collection Request

Application for Help with Medicare Prescription Drug Plan Costs

ICR 201710-0960-008 · 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 Modified Repair queued
Form i1020 Internet Application for Help with Medicare Prescription Drug Plan Costs Form and Instruction Modified Available
Supporting Statement - 0696.docx Supporting Statement A Uploaded 2018-03-14 Repair queued
Addendum - 0696.docx Supplementary Document Uploaded 2018-02-07 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
38067 Application for Help with Medicare Prescription Drug Plan Costs (Paper Form) Form and Instruction Modified
187636 Application for Extra Help With Medicare Prescription Drug Plan Costs (field office interview) Other-Screens for SSA field office interview Modified
182917 Internet Application for Help with Medicare Prescription Drug Plan Costs Form and Instruction Modified
ICR Details
0960-0696 201710-0960-008
Historical Active 201409-0960-010
SSA
Application for Help with Medicare Prescription Drug Plan Costs
Revision of a currently approved collection   No
Regular
Approved without change 06/21/2018
Retrieve Notice of Action (NOA) 03/14/2018
In accordance with 5 CFR 1320, the information collection is approved for three years.
  Inventory as of this Action Requested Previously Approved
06/30/2021 36 Months From Approved 06/30/2018
986,551 0 1,054,985
464,389 0 503,974
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. The respondents are Medicare beneficiaries or applicants applying for Part D low income subsidy.
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
  82 FR 55707 11/22/2017
83 FR 4722 02/01/2018
No
  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 986,551 1,054,985 0 0 -68,434 0
Annual Time Burden (Hours) 464,389 503,974 0 0 -39,585 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
When we last cleared this IC in 2015, the burden was 503,974 hours. However, we are currently reporting a burden of 464,389 hours. This change stems from a decrease in the number of responses from Medicare beneficiaries applying for Extra Help from 1,054,985 to 986,551.
$2,163,411
No
    Yes
    Yes
No
No
No
Uncollected
Faye Lipsky 410 965-8783 [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.
03/14/2018