Social Security Information
The Medicare Prescription Drug program began on January 1, 2006.
This program gives you a choice of prescription plans that offer
various types of coverage.
You may be able to get extra help to pay for the premiums,
annual deductible, and co-payments related to the Medicare
Prescription Drug program. However, you must be enrolled in a
Medicare Prescription Drug plan to get this extra help.
It is an application for extra help with the prescription drug
costs. It is not an application for coverage under a
prescription drug plan. You will have to enroll
directly with an approved Medicare prescription drug provider
for coverage. If you need information about the new Medicare
Prescription Drug Program, visit www.medicare.gov or call
1-800-MEDICARE
(TTY 1-877-486-2048).
You should complete this application for extra help on the Internet if:
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You have Medicare Part A (Hospital Insurance) and/or
Medicare Part B (Medical Insurance); and
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You live in one of the 50 states or the District of Columbia; and
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Your combined savings, investments, and real estate (other than your home)
are not worth more than $11,710, if you are single,
or $23,410 if you are married and living with your spouse.
If you have more than those amounts, you may not qualify for the extra
help. However, you can still enroll in an approved Medicare prescription
drug plan for coverage.
EXCEPTION: Even if you meet these conditions,
do NOT complete this application if any of
the following apply:
-
You receive Supplemental Security Income (SSI) payments
and have Medicare;
-
You receive Medicaid and have Medicare; or
-
Your state pays your Medicare premiums.
If one or more of these exceptions apply, you will automatically
get the extra help, and you will be contacted about receiving it.
To get extra help with prescription drug costs, you must
complete and submit this application. We will review your
application and send you a letter to let you know if you
qualify for extra help. We also will send you information
about the Medicare Prescription Drug Program and tell you what
you should do next.
If you need help completing this application, call Social
Security toll-free at 1-800-772-1213.
If you are deaf or hard of hearing, call our toll-free TTY number at
1-800-325-0778.
Privacy Act Statement
Social Security is allowed to collect the facts on this
application under Section 205 of the Social Security Act.
We need this information to efficiently process your Internet
application. Giving us these facts is voluntary. However,
without them we may not be able to process your application
online. Social Security may provide information collected on
this application to another Federal, State, or local
government agency to assist us in determining your
eligibility for the extra help or if a Federal law
requires the release of information. We also may need
to share the information with other Social Security programs
if Social Security needs to determine your eligibility in
those programs.
We may also use the information you give us when we match
records by computer. Matching programs compare our records
with those of other Federal, State, or local government
agencies. Many agencies may use matching programs to find
or prove that a person qualifies for benefits paid by the
Federal government. The law allows us to do this even if
you do not agree to it. Explanations about these and other
reasons why information you provide us may be used or given
out are available in Social Security offices. If you want
to read more information on this subject, read
The Collection and Use of Information From Your Application -
Privacy Act Statement.
Social Security has access to the information you provide on
this application and is authorized to keep information on
applications that were partially completed. This is for
purposes of helping you complete the application process. If
you have decided you want to continue, you can apply now or,
if you are undecided, you may file at a later time.
