Appeal of Determination for Help with Medicare Prescription Drug Plan Costs

SSA uses Form SSA-1021, Appeal of Determination for Help With Medicare Prescription Drug Plan Costs, to obtain information from individuals who appeal SSA’s decisions regarding eligibility or continuing eligibility for a Medicare Part D subsidy. The respondents are Medicare beneficiaries, or proper applicants acting on behalf of a Medicare beneficiary, who do not agree with the outcome of an SSA subsidy eligibility determination, and are filing an appeal. We are doing a non-substantive change request to replace Medicare Claim Number with Medicare Beneficiary Identifier.

The latest form for Appeal of Determination for Help with Medicare Prescription Drug Plan Costs expires 2021-01-31 and can be found here.

Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version

Federal Enterprise Architecture: Income Security - General Retirement and Disability

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