OMB control number
Appeal of Determination for Help with Medicare Prescription Drug Plan Costs
OMB 0960-0695 · SSA.
OMB 0960-0695
SSA uses Form SSA-1021, Appeal of Determination for Help With Medicare Prescription Drug Plan Costs, to obtain information from individuals who appeal SSA’s decisions regarding eligibility or continuing eligibility for a Medicare Part D subsidy. The respondents are Medicare beneficiaries, or proper applicants acting on behalf of a Medicare beneficiary, who do not agree with the outcome of an SSA subsidy eligibility determination, and are filing an appeal.
The latest form for Appeal of Determination for Help with Medicare Prescription Drug Plan Costs expires 2027-11-30 and is listed under ICR 202312-0960-004.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Addendum - 0695 (Final).docx | Supplementary Document |
| Supporting Statement - 0695 (Final).docx | Supporting Statement A |
 Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version |
Instruction |
| Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - MAPS Intranet Version |
Other-Intranet Screens |
All Historical Document Collections
OMB Details
Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version
Federal Enterprise Architecture: Income Security - General Retirement and Disability
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form | www.ssa.gov | Instruction | |
| Form SSA-1021 | Appeal of Determination for Help with Medicare Prescription Drug Plan Costs | www.ssa.gov | Form |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.