372 lines
16 KiB
HTML
372 lines
16 KiB
HTML
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<style>
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#fw-formInfo li h4 {
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color: black !important
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} </style>
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<!doctype html>
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<html id="Ee001" lang="en">
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<head>
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<meta name="checkpointVersion" content="1.0.39" />
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<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" />
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<meta http-equiv="Cache-Control" content="proxy-revalidate" />
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<meta http-equiv="Cache-Control" content="max-age=0" />
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<title>Welcome!, Extra Help With Medicare Prescription Drug Plan Costs, Social Security</title>
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<style>
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@import url(https://www.ssa.gov/flexweb/rel_4_6/styles/import.css);
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</style>
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<script src="https://www.ssa.gov/flexweb/rel_4_6/libs/wforms/wforms_pack.js"></script>
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<script type="text/javascript">if (SSA.page && SSA.page.timeout) { SSA.page.timeout.config({url:"Controller"}); }</script>
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<script type="text/javascript">
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/*<![CDATA[*/
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document.cookie = "IV_JCT=%2Fi1020; path=/;secure";
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/*]]>*/
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</script>
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</head>
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<body id="fw-app" class="fw-thmNeo disablePageExit disablePageTimeout">
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<div id="fw-container">
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<div id="fw-header" role="banner">
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<a id="fw-skipNav" href="#fw-content" accesskey="K">Skip to Content</a>
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<div id="fw-websiteIdentity">
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<div id="fw-logo">
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<a href="http://www.socialsecurity.gov/" target="_blank">
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<img src="https://www.ssa.gov/flexweb/rel_4_6/images/ssa-logo-52x38.png" alt="SSA Logo"/>
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</a>
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</div>
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<div id="fw-websiteTitle">
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<h1>Social Security</h1><p id="fw-tagline">
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The Official Website of the U.S. Social Security Administration
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</p>
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</div>
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</div>
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<div id="fw-global">
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<ul id="fw-globalOptions">
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<li id="fw-language" class="fw-first"><a target="_self" href="startEs">Español</a></li><li id="fw-textsize"><a rel="msg" target="_blank" href="http://www.socialsecurity.gov/webcontent/textsize.htm">Need Larger Text?</a></li><li id="fw-accessibility"><a rel="msg" target="_blank" href="http://www.socialsecurity.gov/accessibility/">Accessibility Help</a></li></ul>
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</div>
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</div>
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<noscript>
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<div id="fw-JavaScriptOff">
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<div class="yui3-g">
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<div class="yui3-u-3-4">
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<div class="content">
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<div class="uef-important uef-notice module">
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<div class="hd">
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<h4 tabindex="0">
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JavaScript is required to use this service
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</h4>
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</div>
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<div class="bd">
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<p>Social Security's online services are designed to be accessible and user-friendly. That is why we require all web browsers to have JavaScript enabled when working with our online services.</p>
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<p>To use this service, please adjust your web browser settings to enable JavaScript, then <a href="/i1020/start">try again</a>.</p>
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<p>If you can't or don't want to enable JavaScript, you can return to the <a href="http://www.socialsecurity.gov/">Social Security home page</a>.</p>
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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</noscript>
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<div id="fw-main" class="hide">
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<script>
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var jsOffMsg = document.getElementById("fw-JavaScriptOff");
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if(jsOffMsg) {jsOffMsg.parentNode.removeChild(jsOffMsg);}
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var mainSection = document.getElementById("fw-main");
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if(mainSection) {YAHOO.util.Dom.removeClass(mainSection, "hide");}
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</script>
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<div id="fw-pageTitle" class="section">
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<h2>Extra Help With Medicare Prescription Drug Plan Costs</h2>
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<ul id="fw-formInfo">
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<li><h4>OMB No. 0960-0696</h4></li>
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<li><a href="http://www.ssa.gov/hlp/pr-act/pra-i1020.html " rel="info" target="_blank">Paperwork Reduction Act</a></li>
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</ul>
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</div>
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<div id="fw-content" role="main">
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<form id="Ee001" name="Ee001" action="/i1020/Ee001.action" method="post">
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<input type="hidden" name="struts.token.name" value="token" />
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<input type="hidden" name="token" value="DFLU0RP47GWK8BLMJSYS6HA823F5GC4" />
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<div class="yui3-g">
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<div class="yui3-u-3-4">
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<div class="content">
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<h3><strong>Welcome!</strong></h3>
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<p>The Medicare Prescription Drug program gives you a choice of prescription plans that offer various types of coverage.</p>
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<p>You may be able to get extra help to pay for the monthly premiums, annual deductibles, 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.</p>
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<h4><strong>What Is This Application?</strong></h4>
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<br />
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<p>This is an application for Extra Help and <strong>does not enroll you in a Medicare prescription drug plan</strong>. You will have to enroll directly with an approved Medicare prescription drug provider for coverage. If you need information about Medicare Prescription Drug plans or how to enroll in a plan, call <strong>1-800-MEDICARE (TTY 1-877-486-2048)</strong> or visit
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<a href="http://www.medicare.gov" rel="msg" target="_blank">www.medicare.gov</a>.
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</p>
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<h4><strong>Who Should Complete This Application For Extra Help With Medicare Prescription Drug Plan Costs?</strong></h4>
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<br />
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<p>You should complete this application for Extra Help on the Internet if: </p>
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<ul>
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<li>You have Medicare Part A (Hospital Insurance) and/or Medicare Part B (Medical Insurance); and</li>
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<li>You live in one of the 50 States or the District of Columbia; and</li>
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<li>Your combined savings, investments, and real estate are not worth more than $35,130, if you are married and living with your spouse, or $17,600 if you are not currently married or not living with your spouse. <strong>(Do NOT count your home, vehicles, personal possessions, life insurance, burial plots, irrevocable burial contracts or back payments from Social Security or SSI.)</strong> 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. </li>
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</ul>
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<p><strong>EXCEPTION</strong>: Even if you meet these conditions, <strong>DO NOT</strong> complete this application if you have Medicare <strong>and</strong> Supplemental Security Income (SSI) or Medicare <strong>and</strong> Medicaid because you automatically will get the extra help. </p>
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<h4><strong>How Can You Get The Extra Help?</strong></h4>
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<br />
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<p>To get extra help with Medicare Prescription Drug plan costs, you <strong>must complete and submit this application</strong>. We will review your application and send you a letter to let you know if you qualify for extra help.</p>
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<p><strong>NOTE</strong>: To apply, you must live in one of the 50 States or the District of Columbia.</p>
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<p>If you need help completing this application, call Social Security toll-free at <strong>1-800-772-1213</strong> (TTY <strong>1-800-325-0778</strong>).</p>
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<p><strong>You also may be able to get help from your State with other Medicare costs under the Medicare Savings Programs. </strong> By completing this form, you will start your application process for a Medicare Savings Program. We will send information to your State who will contact you to help you apply for a Medicare Savings Program unless you tell us not to when you complete this application.</p>
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If you need information about Medicare Savings Programs, Medicare Prescription Drug plans or how to enroll in a plan, call <strong>1-800-MEDICARE</strong> (TTY <strong>1-877-486-2048</strong>) or visit
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<a href="http://www.medicare.gov" rel="msg" target="_blank">www.medicare.gov</a>.
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You also can request information about how to contact your State Health Insurance Counseling and Assistance Program (SHIP). The SHIP offers help with your Medicare questions. <p/>
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<div class="yui3-g">
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<div class="yui3-u-1-2">
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<div class="content">
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<div class="uef-container equalHeight-buttonBox module">
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<div class="bd">
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<h4><strong>What Do You Want To Do?</strong></h4>
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<p>
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<input type="submit" value="Apply Now" name="ACTION.START"
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id="action.start" class="uef-btn"/>
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<br />
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<input type="submit" value="Return to an Existing Application" name="ACTION.RESTART"
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id="action.restart" class="uef-btn"/></p>
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</div>
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</div>
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</div>
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</div>
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<div class="yui3-u-1-2">
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<div class="content">
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<div class="uef-container equalHeight-buttonBox module">
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<div class="bd">
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<h4><strong>Not Sure If You Should Use This?</strong></h4>
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<p>
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<input type="submit" value="Find Out If You Qualify" name="ACTION.QUALIFIER"
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id="action.qualifier" class="uef-btn"/></p>
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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<div class="yui3-u-1-4">
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<div class="content">
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<div class="uef-container module">
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<div class="bd">
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<div>
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<p>If you need help completing this application, call Social Security toll-free at: <br/> <strong>1-800-772-1213</strong> or <br/>TTY <strong>1-800-325-0778</strong>, <br/>Monday-Friday 7am-7pm</p>
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</div>
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</div>
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</div>
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<div class="uef-container module">
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<div class="bd">
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<div>
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<h3>Related Links</h3>
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<br />
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<p>Information About This Application:</p>
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<ul>
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<li><a href="./msgpages/Msg106.jsp" rel="msg" target="_blank">What You Will Need</a></li>
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<li><a href="./msgpages/Msg061.jsp" rel="msg" target="_blank">Other Ways To Apply</a>
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</li>
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<li><a href="./msgpages/Msg023.jsp" rel="msg" target="_blank">How The Online Application Works</a>
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</li>
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</ul>
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<p>Legal and Official Information:</p>
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<ul>
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<li><a href="./msgpages/Msg004.jsp" rel="msg" target="_blank">Internet Security Policy</a>
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</li>
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</ul>
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<p>Medicare Information:</p>
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<ul>
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<li><a href="https://www.ssa.gov/medicare/part-d-extra-help/" rel="msg" target="_blank">About the Prescription Drug Program</a>
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</li>
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<li><a href="http://www.medicare.gov" rel="msg" target="_blank">Official U.S. Government Medicare Site</a>
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</li>
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<li><a href="http://www.cms.hhs.gov" rel="msg" target="_blank">Centers For Medicare & Medicaid Services</a>
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</li>
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</ul>
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</div>
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</div>
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</div>
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<div class="uef-container module">
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<div class="bd ft">
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<div>
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<p><strong>Your privacy is important.</strong> <br/> For details about our use of your information, we encourage you to read our
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<a href="./msgpages/Msg074.jsp" rel="msg" target="_blank">Privacy Act Statement.</a>
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</p>
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</div>
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</div>
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</div>
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</div>
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</div>
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</form>
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</div>
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</div>
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<div id="fw-footer" role="contentinfo"><p>
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<a href="http://ssa.gov/privacy.html" rel="msg" target="_blank">Privacy Policy</a>
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<a href="http://www.socialsecurity.gov/websitepolicies.htm" rel="msg" target="_blank">Website Policies & Other Important Information</a>
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<a href="http://ssa.gov/sitemap.htm" rel="msg" target="_blank">Site Map</a>
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</p></div>
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</div>
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</body>
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</html>
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