Addendum to Supporting 0618

Addendum to the Supporting Statement for Social Security Benefits Application:

Form SSA-1: Application for Retirement Insurance Benefits

Form SSA-2: Application for Wife’s or Husband’s Insurance Benefits

Form SSA-16: Application for Disability Insurance Benefits

Internet Claim (iClaim) Application Screens

20 CFR 404.310-404.311, 404.315-404.322, 404.330-404.333, 404.601-404.603, and 404.1501-404.1512

OMB No. 0960-0618

Revision to the Collection Instruments

This addendum summarizes the changes to the three modalities (paper forms SSA-1, SSA-2, and SSA-16, interview/MCS and internet/iClaim); changes to the paper form will also change in MCS, Internet, and iClaim.

SSA-1

• Change #1: We are removing question #20, “May we ask your employers for wage information needed to process your claim?” from the Retirement Insurance Benefit Application, and realigning the numbers for the questions on the SSA-1 due to the removal of question 20.

Justification #1: We are removing this question because the agency does not need

permission from the individuals to request information from their employers to develop current or prior year earnings, due to the agency’s routine use authority in the applicable systems of records notices. Therefore, it is no longer necessary for respondents to complete this question.

• Change #2: On the Medicare Information section on page 5, we are changing the reference to the next question:

From: COMPLETE ITEM 27 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER

To: COMPLETE ITEM 26 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER.

Justification #2: We are removing question 20 from the SSA-1 per change #1. Removing question 20 changes the numbering of the remaining questions and changes question 27 to question 26, which is located on page 5 of the SSA-1.

SSA-1 and SSA-2 and internet/iClaim

• Change #3: We are adding the following information on page 5 of both applications and under the section titled “Medicare Information” for iClaim:

• Late Enrollment Penalty “If you do not sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty for as long as you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but did not sign up for it. Also, you may have to wait until the General Enrollment Period (January 1 to March 31) to enroll in Part B and coverage will start July 1 of that year.”

• For internet/iClaim, we are adding the following message when the applicant’s response is “no” to the question, “Do you want to enroll in Medicare Part B?”, “You cannot enroll in Part B at any time.  Enrolling later can mean lifetime late enrollment penalties added to your monthly premium. If you do not enroll in Medicare Part B when you are first eligible and then decide to enroll later, your coverage may not start right away and you may also have to pay a lifetime late enrollment penalty – and that penalty increases the longer you wait.  Click the More Info button to learn more.”

Justification #3: We are adding this language in response to advocacy concerns that applicants do not understand that refusing Part B of Medicare could result in delayed coverage and a late enrollment penalty. This language reflects the information SSA employees provide when interviewing an individual who is filing for benefits or Medicare Part A and refuses Medicare Part B.

• Change #4: On the Medicare Information section on page 5, we are changing the reference to the next question:

• From: COMPLETE ITEM 27 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER

• To: COMPLETE ITEM 26 ONLY IF YOU ARE WITHIN 3 MONTHS OF AGE 65 OR OLDER.

• Justification #4: We are removing question 20 from the SSA-1 per change #1. Removing question 20 changes the numbering of the remaining questions and changes question 27 to question 26, which is located on page 5 of the SSA-1.

SSA-16

• Change #5: We are removing the question 19, “May the Social Security Administration or State agency reviewing your case, ask your employers for information needed to process the claim?” from the Application for Disability Insurance Benefits, and realigning the numbers on SSA-16 due to removal of question 19.

Justification #5: We are removing this question because under the Privacy Act routine use, SSA has the authority to disclose claimant information from the Claims Folder to an employer to request information needed to determine an individual’s eligibility for benefits. Therefore, it is no longer necessary for respondents to complete this question.

• Change #6: We are adding a blind question to the SSA-16 (Disability Insurance Application), modifying the blind question in MCS and iClaim, and realigning the numbers of the SSA-16.

• Paper application, SSA-16, we are adding the question, “Are you blind or do you have low vision even with glasses or contacts?” after question #22 and before question #23 on page 4.

• Interview/MCS - On the Disability (DISB) screen, the current language reads, BLIND (Y/N). We are revising this language to read, “BLIND OR LOW VISION (Y/N).”

• Internet/iClaim - On the Applicant Information screen, the current language reads, “Are you blind? We are revising this language to read, Are you blind or do you have lo vision even with glasses or contacts?”

• Justification #6: There are special rules for people who are blind or have low vision.

We are adding low vision to the blind question to capture claimants who may not consider themselves blind, but have a visual acuity that meets the statutory blindness requirements.

We will make these changes upon OMB’s approval of this information collection request.