MSP Follow-Up Letter for 2010

[REVERSE]

DATE OF MAILING

ADDRESS 1

ADDRESS 2

ADDRESS 3

ADDRESS 4

ADDRESS 5

ADDRESS 6

We recently received your application for Extra Help with your Medicare prescription drug coverage. Because of a new law that starts in 2010, we will no longer count the value of any life insurance policy as a resource. In addition, we will no longer count payments other people make for your food and shelter as income.

Also, you may be able to get help from your State with other medical costs through a Medicare Savings Program. Medicare Savings Programs help people with limited income and resources save more than $1,100 a year by paying for their Medicare Part B premiums. In some cases, Medicare Savings Programs can help pay Medicare Part A premiums (if any) and may also help with Medicare deductibles and co-payments. We are now able to send information to your State from your Social Security Extra Help decision to see if you can get the benefit of a Medicare Savings Program.

How to Apply for a Medicare Savings Program

Simply complete the enclosed statement to let us know if you are interested in Social Security sending this information to your State. Then mail it back to us in the preaddressed, postage-paid envelope. By checking “Yes”, you will start your application process for a Medicare Savings Program. We will send information from your Extra Help decision to your state office. Your state office will contact you to help you apply for the program. If we do not receive the signed statement from you within 20 days from the date of this letter, we will not send the information to your state office.

If You Have Any Questions

If you need information about Medicare Savings Programs, Medicare Prescription Drug Plans, or how to enroll in a plan, please visit Medicare online at www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227; TTY, 1-877-486-2048). You can also request information from your State Health Insurance Assistance Program (SHIP). Your local SHIP phone number is located on the back of your Medicare and You, 2010 handbook. To request a copy of the handbook or for more information about the SHIP in your state, you can call Medicare’s toll free number (1-800-Medicare) or visit them online.

Carolyn L. Simmons

Associate Commissioner for

Central Operations

Privacy Act / Paperwork Reduction Notice

Section 113 of the Medicare Improvements for Patients and Providers Act of 2008, Public Law 110-275, authorizes the disclosure of information we used to decide your level of extra help, with your consent, to your state medical assistance (Medicaid) office to see if you qualify for a Medicare Savings Program. The information you provide will be forwarded by the Social Security Administration (SSA) to State Agencies so they can initiate your application process for the Medicare Savings Programs. You do not have to consent to this disclosure. However, if you do not consent, we will be unable to notify the state to initiate the application process. Your records are confidential. We will release your records to the state medical assistance (Medicaid) office only for the purpose of this authorization.

Paperwork Reduction Act Statement — This information collection, OMB No. 0960-0696, meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take less than 4 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

SEND THE COMPLETED FORM TO US AT THE ADDRESS SHOWN ON THE ENCLOSED PRE-ADDRESSED ENVELOPE TO:

Social Security Administration

Wilkes-Barre Data Operations Center

P.O. Box 3988

Wilkes-Barre, PA 18767-9970

FROM: TO:

ADDRESS 1 Social Security Administration

ADDRESS 2 Wilkes-Barre Data Operations Center

ADDRESS 3 P.O. Box 3988

ADDRESS 4 Wilkes-Barre, PA 18767-9970

ADDRESS 5

ADDRESS 6

[ ] YES, I/we want to see if I/we qualify for a Medicare Savings Program.

[ ] NO, I do not want to see if I qualify for a Medicare Savings Program.

INSTRUCTIONS: Place an X in the YES box if you want to apply for a Medicare Savings Program. Place an X in the NO box if you do not want to apply for a Medicare Savings Program.

By checking the “Yes” block above and submitting this form, I am/we are authorizing the Social Security Administration (SSA) to obtain and disclose information related to my/our income, resources, and assets, foreign and domestic, consistent with applicable privacy laws, to my state medical assistance (Medicaid) office to see if I/we qualify for a Medicare Savings Program. This information may include, but is not limited to, information about my/our wages, account balances, investments, benefits, and pensions. I am/we are authorizing SSA to disclose to the state the financial information listed above and other individually identifiable information from my/our file, such as my/our name(s), date of birth, gender and social security number(s) to start the application process for a Medicare Savings Program.

By checking the “No” block above and submitting this form, I am/we are saying that I/we do not want SSA to disclose any information to my state medical assistance (Medicaid) office for the purpose of starting an application for Medicare Savings Program.

Signature (you or your legal guardian):	Date:
Spouse’s Signature (spouse or spouse’s legal guardian):	Date:

IMPORTANT INFORMATION: If you do not return this form, you will not be consenting to this disclosure. We will be unable to send your information to the state medical (Medicaid) assistance office. If you are married and living with your spouse, you and your spouse, or your legal guardians must sign this form.