Form Ssa-1026b-Ocr-Sm-Inst - Statement Foe Continuing Eligibility For Extra Help With Medicare Prescription Drug Plan Costs
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10Social Security Administration
Review Of Your Eligibility For
Extra Help
THIS COVER LETTER IS FOR INFORMATION ONLY.
DO NOT COMPLETE THE FOLLOWING PAGES.
THIS IS NOT AN APPLICATION.
We must review your eligibility for Extra Help with Medicare prescription drug plan costs.
We will check to be sure that you are still eligible and that your Extra Help, also known as
the subsidy, is correct. We want to make this review as simple as possible for you, so you will
not need to visit the office.
What We Will Do To Review Your Case
As part of the review, we will look at current information in our records. Your continued
eligibility is determined by the amount of your resources, income and household size. If you
have a spouse and you are living together, your total resources and income count.
What You Need To Do For This Review
• Please complete the enclosed form; do not use the form on the Internet website.
• Refer to the Resources and Income Summary on the back of this letter when
completing the form.
• Sign and return the form in the enclosed envelope within 30 days.
If You Do Not Return This Form
If you do not return this form within 30 days, your help with Medicare prescription drug
plan costs will be terminated. If you are waiting for information from another agency or need
assistance, you can call Social Security toll-free at 1-800-772-1213 (TTY 1-800-325-0778).
If you do need assistance, we can give you an additional 30 days to return the form to us.
Social Security Administration
Enclosures
SSA-1026B-OCR-SM-INST
Form
(08-2012) Recycle prior editions
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