ADDENDUM TO SUPPORTING STATEMENT
Revision to the Collection Instrument
We are revising the SSA-1020/i1020 form to align it with P.L. 110-275 (Medicare Improvements for Patients and Providers Act of 2008) and to increase clarity. However, we will continue to use the old forms until the stock runs out. Details of the changes are below.
Changes to SSA-1020
Change 1: We corrected the SHIP acronym to State Health Insurance Counseling and Assistance Program on page one, last paragraph.
Current Language: State Health Insurance Assistance Program (SHIP)
Revised Language: State Health Insurance Counseling and Assistance Program
Justification 1: We changed the SHIP acronym to the correct State Health Insurance Counseling and Assistance Program, because the name changed.
Change 2: We capitalized each occurrence of the letter ‘S” in the word State, throughout the document.
Justification 2: We made this change to be consistent throughout the document.
Change3: We added “life insurance” to the list of assets on page 2, question #3 that we do not count.
Current Language: If you are married and living with your spouse, do you have savings, investments or real estate worth more than $25,260? If you are not married or you do not live with your spouse, is the value more than $12,640? Do NOT count the home you live in, vehicles, personal possessions, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.
Revised Language: If you are married and live with your spouse, do you have savings,investments or real estate worth more than $25,260? If you are not married or you do not live with your spouse, is the value more than $12,640? Do NOT count your home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.
Justification 3: Effective January 1, 2010, we no longer count the value of any life insurance policy as a resource for Extra Help. We also streamlined the wording in the question so that “life insurance” would not affect optical sensor formatting when we translate to Spanish.
Change 4:
We changed the household composition question (# 7) on page 3.
Current language: 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.
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 you and your spouse, place an X in the NONE box.
Revised language: For this question, a relative is someone related to you by blood, adoption, or marriage (but not including your spouse). How many relatives live with you and depend on you or your spouse for at least one-half of their financial support?
Please do not include yourself or your spouse in the number you enter. If your household consists only of you or you and your spouse, place an X in the ZERO box. Place an X in only one box.
Justification 4: Our Office of Quality Performance conducted a Low Income Subsidy Awards review and determined a large number of errors on the household composition question. We revised the language to reduce errors.
Change 5: We are adding the word “unemployment” to page 4, question 8 under the “Other income” category, on the Income Other Than Wages and Earnings Section. We are changing the question from:
Current Language: Other income not listed above, including alimony, net rental income, workers compensation, private or state disability payments, etc. (Specify):_______
Revised Language: Other income not listed above, including alimony, net rental income, workers compensation, unemployment, private or state disability payments, etc. (Specify):_______
Justification 5: Our Office of Quality Performance conducted a Low Income Subsidy Awards review and found that a number of application errors are due to unreported unemployment income. We revised the language in an effort to reduce these errors.
Change 6: We are changing the years on page 5, question 13 to reflect the form’s renewal.
Current Language: If you or your spouse, stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012, enter the month and year:
Revised Language: If you or your spouse, stopped working in 2011 or 2012, or plan to stop working in 2012 or 2013, enter the month and year:
Justification 6: We are renewing the form for use after OMB clearance, and want to update the years in which we ask about changes in income as well as the example for ease of use by the public.
Change 7: We are changing the example on page 5, question 13, to reflect the year in which we ask about changes form’s renewal.
Current Language: For January – September, place a zero (0) in the first box. May 2010 should read:
Revised Language: For January – September, place a zero (0) in the first box. May 2012 should read:
Justification 7: We are renewing the form for use after OMB clearance, and want to update the years in which we ask about changes in income.
Changes to i1020
Change 8: We corrected the SHIP acronym to State Health Insurance Counseling and Assistance Program on page one, Screens A.2.1 Welcome Screen.
Current Language: State Health Insurance Assistance Program (SHIP)
Revised Language: State Health Insurance Counseling and Assistance Program
Justification 8: We changed the SHIP acronym to the correct State Health Insurance Counseling and Assistance Program, because the name changed.
Change 9: We capitalized each occurrence of the letter ‘S” in the word State, throughout the screens.
Justification 9: We made this change to be consistent throughout the application.
Change 10: We added “life insurance” to the list of assets on the Should You Use This Application Screen. We also simplified the question by changing “the home you live in” to “your home.”
Current Language: If you are married and living with your spouse, do you have savings, investments or real estate worth more than $25,260? If you are not married or you do not live with your spouse, is the value more than $12,640? Do NOT count the home you live in, vehicles, personal possessions, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.
Revised Language: If you are married and live with your spouse, do you have savings, investments or real estate worth more than $25,260? If you are not married or you do not live with your spouse, is the value more than $12,640? Do NOT your home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.
Justification 10:
Effective January 1, 2010, we no longer count the value of any life insurance policy as a resource for Extra Help. We also streamlined the wording in the question so that “life insurance” would not affect optical sensor formatting when we translate to Spanish.
Change 11: We changed the household composition question (# 7) on page 3.
Current language: 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.
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 you and your spouse, place an X in the NONE box.
Revised language: For this question, a relative is someone related to you by blood, adoption, or marriage (but not including your spouse). How many relatives live with you and depend on you or your spouse for at least one-half of their financial support?
Please do not include yourself or your spouse in the number you enter. If your household consists only of you or you and your spouse, place an X in the ZERO box. Place an X in only one box.
Justification 11: Our Office of Quality Performance conducted a Low Income Subsidy Awards review and determined a large number of errors on the household composition question. We revised the language to reduce errors.
Change 12: We are adding the word “unemployment” to the “Other income” category, on the Income Other Than Wages and Earning Screen, Find Out If You and Your Spouse Qualify screen, Find Out If You Qualify screens, and Tool: Add Up Your Types of Income screen.
Current Language: Other income not listed above, including alimony, net rental income, workers compensation, private or state disability payments, etc. (Specify):_______
Revised Language: Other income not listed above, including alimony, net rental income, workers compensation, unemployment, private or state disability payments, etc. (Specify):_______
Justification 12: Our Office of Quality Performance conducted a Low Income Subsidy Awards review and found that a number of application errors are due to unreported unemployment income. This change is to reduce these errors.
Change 13: We are changing the years in wage and self- employment questions to reflect the form’s renewal date, on the Find Out If You And Your Spouse Qualify screen, and Find Out If you Qualify screens.
Current Language: If you or your spouse, stopped working in 2010 or 2011, or plan to stop working in 2011 or 2012, enter the month and year:
Revised Language: If you or your spouse, stopped working in 2011 or 2012, or plan to stop working in 2012 or 2013, enter the month and year:
Justification 13: We are renewing the form for use beginning in February 2012, so we would like to update the years in which we ask about changes in income as well as the example for ease of use by the public.
We are revising the PRA statement to reflect our current boilerplate language. The current language, which dates back to the last reprint of the form, is now outdated.
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 Statement on the first page of the form.
| File Type | application/msword |
| Author | 889123 |
| Last Modified By | 889123 |
| File Modified | 2012-02-14 |
| File Created | 2011-12-20 |