Addendum to Supporting Statement 0960-0269

0960-0269

HA-501

Addendum to Supporting Statement

Planned Changes

NOTE: Below are the changes we will make to form HA-501.

Changes to page 1:

• Added Claimant’s Social Security Number (Q.1.)

Reason for change: SSN is needed for identification purposes for the Medicare Part B IRMAA.

• Added “If Different” to Claim Number (Q.2.)

Reason for change: If the claimant’s Social Security number and Claim Number are the same, there is no reason to provide both.

• Added Spouse’s Name If Not Wage Earner and Spouse’s Social Security number (Q.4.)

Reason for change: The spouse’s name (if not the wage earner) and SSN is needed to be consistent with the reconsideration process.

• Changed “Administrative Law Judge of the Office of Hearings and Appeals ….” to “Administrative Law Judge of the Office of Disability Adjudication and Review or Health and Human Services….”

Reason for change: OHA component name was changed to ODAR and added HHS to indicate that HHS ALJs may be conducting the hearing.

• Added to Q.7. “Do not complete if appeal is a Medicare issue.”

Reason for change: If the appeal involves a Medicare issue, the HHS ALJs default to a video-teleconference unless the claimant requests otherwise in writing.

• Added to the information involving claimant’s representative “unless you are appealing a Medicare issue.” (3rd line). Added: Regardless of the issue you are appealing” (4^th line)

Reason for change: An appeal involving a Medicare issue will require written documentation for the HHS ALJs other than the SSA-1696.

• Added to Q.15. “Title XVIII (HI/SMI)”

Reason for change: to bring the form up to date for use with Medicare entitlement/Part B issues

• Added to Q.16. a block denoting “electronic folder” and a block to Q.16 and Q.17 denoting “title XVIII.” Also, Q.16, changed “teletype” to “email” in parenthetical instruction.

Reason for change: to bring the form up-to-date, e.g., for use with Medicare/ entitlement/ Part B issues and electronic file processing

Changes to page 2:

• Added “section 1839(i) of the Act (P.L. 108-173)”

Reason for change: to bring the Paperwork/Privacy Act Notice language up to date with Part B Income-Related Monthly Adjustment Amount (IRMAA) provision

0960-0269

Addendum

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