Application for Help with Medicare Prescription Drug Plan Costs

OMB 0960-0696

OMB 0960-0696

The Medicare Modernization Act of 2003 mandated the creation of the Medicare Part D prescription drug coverage program and provided for certain subsidies for eligible Medicare beneficiaries to help pay for the costs of prescription drugs. SSA uses Form SSA-1020 (and the i1020, its electronic counterpart), the Application for Extra Help with Medicare Prescription Drug Plan Costs, to collect information to make Part D subsidy eligibility determinations. The respondents are Medicare beneficiaries or applicants applying for Part D low income subsidy. We are doing a non-substantive change request to replace Medicare Claim Number with Medicare Beneficiary Identifier.

The latest form for Application for Help with Medicare Prescription Drug Plan Costs expires 2021-06-30 and can be found here.

OMB Details

Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form SSA-1020Application for Help with Medicare Prescription Drug Plan CostsPaper OnlyForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.


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