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What You Need To Complete The Application For Help With Medicare Prescription Drug Plan Costs 2006

SSA Publication No. 05-10128, March 2006, ICN 480068 ( View .pdf)  spacer (En Espaol) (other languages)
 

Social Security and the Centers for Medicare & Medicaid Services are working together to get you extra help with your prescription drug costs. To determine if you could be eligible for this extra help, Social Security will need to know your income and the value of your savings, investments and real estate (other than your home). You may qualify for extra help if you have:

  • Limited income (below $14,700 for an individual or $19,800 for a married couple living together). Even if your annual income is higher, you still may be able to get some help with your monthly premiums, annual deductibles and prescription co-payments. Some examples where your income may be higher include if you or your spouse:

    • Support other family members who live with you;
    • Have earnings from work; or
    • Live in Alaska or Hawaii; and

  • Resources limited to $10,000 for an individual or $20,000 for a married couple living together. These resource limits can be slightly higher (an additional $1,500 per person) if you will use some of your money for burial expenses.
 
 

Contents
What you need to knowspacer spacer
Documents that will help you prepare in advance include:
How you can get more information
Worksheet
 
 

What you need to know

Identify the things you own by yourself, with your spouse or with someone else, but do not include your home, vehicles, burial plots or personal possessions.

Review all your income.

Gather your records in advance to save time.

Remember that this worksheet is not an application. This worksheet can assist you in completing the actual application for extra help.

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Documents that will help you prepare in advance include:

  • Statements that show your account balances at banks, credit unions or other financial institutions;

• Investment statements;

• Life insurance policy statements;

• Stock certificates;

• Tax returns;

• Pension award letters; and

• Payroll slips.

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How you can get more information

If you need an application form, contact Social Security at
1-800-772-1213 (TTY 1-800-325-0778) and ask for the Application for Help with Medicare Prescription Drug Plan Costs (SSA-1020). You can also apply online at www.socialsecurity.gov.

To learn more about the Medicare prescription drug plans, call
1-800-MEDICARE ( 1-800-633-4227) or visit www.medicare.gov.

 

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Please complete the worksheet below.

We need to know information about your (and your spouse’s, if you are married and living together) income and resources:

 
 
Name Social Security Number
   
Resources Value
Bank accounts, including checking, savings and certificates of deposit $ 
Stocks, bonds, savings bonds, mutual funds, individual retirement accounts @(IRAs) or other investments $ 
Cash at home or anywhere else $ 
Life insurance policies for you (and your spouse, if married and living together) $ 
NOTE: Social Security needs to know how much money you would get if you cashed in your life insurance policies today. Check with your insurance company or agent to get the exact cash value. This probably will be less than the amount you are insured for.
Any real estate other than your home $ 
Income Monthly Amount
Social Security Benefits $
Railroad Retirement $ 
Veterans benefits $ 
Other pensions or annuities $ 
Net rental income $ 
Workers' compensation $ 
Help from other people to pay for household expenses, such as food, @mortgage or rent, heating fuel or gas, electricity, water and property taxes $ 
Wages $ 
Self-employment net earnings $ 
Other income $ 
 

You may choose to have someone help you when you do business with Social Security. We will work with that person, just as we would work with you.

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