SSA-1026 -- List and Explanation of Non-Substantive Changes

OMB No. 0960-0723 (Form SSA-1026)

Application for Help with Medicare Prescription Drug Plan Costs

Proposed Non-Substantive Changes

General Note

Below are descriptions of and justifications for SSA’s proposed changes to OMB Form No. 0960-0723 (SSA-1026). Please note that all the changes we are proposing are non-substantive in nature. Additionally, the majority of the changes involve minor wording differences to improve question clarity. The impetus for making these changes comes from Senate and House requests, public advocacy comments at meetings with SSA, our experience processing the applications, and SSA’s continued evaluation of the form. We already made many of the changes listed here last year to parallel questions on form SSA-1020 (OMB No. 0960-0696), the Application for Help with Medicare Prescription Drug Plan Costs; we are planning to make them to the SSA-1026 to ensure continuity between the two forms.

Cover Sheet:

Last paragraph:

Change “may” to “can” in second to last sentence.

Rationale: changed for clarity

Resource and Summary Sheet

Removed: parentheses from “before deductions” under “Income not from Work”

Removed: parentheses from “before deductions” and updated the phrase to be “before taxes and deductions” under “wages” in Earned Income section

Rationale: Changed for clarity

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• Header

Delete statement “To Provide Extra Help in Paying for Your Drug Expense

Rationale:

Removed this statement to mirror the current application for Medicare Part D (SSA-1020, OMB 0960-0696).

• How to Complete This Application:

Change- Deleted “or a # 2 pencil” from the second bullet

Added - “Do not add any handwritten comments on the form.”

Bolded- "Keep your numbers, Xs and letters inside the boxes; use only CAPITAL letters"

Rationale:

Responses recorded using #2 pencils are often too light to scan.

Handwritten comments affect the scanning process of these forms.

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• Header-Will change from:

“THIS DOES NOT ENROLL YOU IN THE MEDICARE PRESCRIPTION DRUG PROGRAM.”

to:

“THIS DOES NOT ENROLL YOU IN A MEDICARE PRESCRIPTION DRUG PLAN.”

Rationale: The revised statement is clearer than the current language and mirrors the wording on the SSA-1020.

• Question 3-Will add:

Line: “Date of change______”

Rationale: We are adding this line so the system can easily identify a change in marital status. There is no additional burden to beneficiaries who have no change in marital status. If there is a change in marital status, beneficiaries will be contacted by their local servicing field office to conduct a more in depth interview.

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• Questions 5-removed the word “red” from “place an X in the red box.-

Rationale: Revised for clarity and to be consistent with the SSA-1020

• Question 6 – Will Change from:

Do you expect to use money from any sources listed in question 5 to pay for funeral or burial expenses for yourself (or your spouse, if married and living together)?

To:

Will some of the money from sources listed in Question 5 be used to pay for funeral or burial expenses?

Rationale: Revised for clarity

Deleted “if living together” from spouse’s response.

Rationale: “If living together” is redundant.

• Question 7-Will change from:

Your household size may affect the amount of help you can get. We need to know how many relatives live with you and your spouse (if married and living together) for whom you or your spouse provide at least one-half of their financial support. Relatives may include anyone related to you by blood, marriage or adoption. Instructions: Please look at the information we have about your household size on the Income and Resources Summary on the back of the enclosed letter. If the information has not changed, place an X in the red block and go to question 8. If the number of these relatives has changed, how many relatives with you now? Place an X in only one box below. If you live alone or only with your spouse check NONE.

To:

Not counting your spouse if you are married, how many other relatives live in your household and receive at least one-half of their financial support from you or your spouse? We count relatives related to you by blood, marriage or adoption. Instructions: Please look at the information we have about your household size on the Income and Resources Summary on the back of the enclosed letter. If the information has not changed, place an X in the box and go to question 8. If the number of relatives has changed, how may relatives live with you now? Place an X in only one box. Do not include yourself or your spouse in the number you enter. If your household consists only of you or your spouse, place an X in the NONE box.

Rationale: Results of reviews conducted by the Office of Quality Performance showed that applicants didn’t understand this question. We revised this wording to further ensure that applicants will respond correctly.

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• Question 8–Will add two additional items applicants should not consider as help:

Question will now read as follows: (change is bolded inside parentheses)

We need to know about help with household expenses that you, your spouse (if married and living together) or both of you receive. Help with household expenses is when anyone provides or helps you pay for any of the following: food, mortgage, rent, heating fuel or gas, electricity, water and property taxes. (It does not include food stamps, house repairs, help from a housing agency, an energy assistance program, Meals on Wheels, contributions from food banks, soup kitchens or help with medical treatment and drugs.) Instructions: Please look at the information we have about help you received with household expenses on the Income and Resources Summary on the back of the enclosed letter.

Rationale: The Senate Aging Committee suggested that the question be revised to expand the list of items that applicants should not consider as help in paying for household expenses. This question also causes a significant percent of errors in processing and is being reworded for clarity.

• Question 9:

Added: “before deductions” after each type of income. Also, reworded “other income” to read: Other income not listed above to include alimony, net rental income, workers’ compensations, etc (Specify)__________

Rationale: Changed for clarity.

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Question 10:

Added: “before taxes and deductions” to Wages

Deleted the word “Your” from “Your Spouse”

Rationale: Changed for clarity

Question 11:

Deleted from spouse “If living together”

Rationale: Change for clarity – phrase is redundant

Question 12:

Deleted from spouse “If living together”

Rationale: Changed for clarity – phrase is redundant

Question 12 Example: Updated date in example to 2008.

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Disclosure statement

Changed the word “application” to “form” in disclosure statement

Rationale: SSA-1026 is not an application, so form is the more technically accurate term.

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