Medicare Part B Income-Related Premium -- Life-Changing Event

Forms and Documents

Document Name	Status
Form SSA-44 (electronic Medicare Part B Income-Related Premium -- Life-Changing Event (screen shots) Form	New
Form SSA-44 Medicare Part B Income-Related Premium -- Life-Changing Event (paper form) Form and Instruction	New
Supporting Statement - SSA-44.doc Supporting Statement A	2006-10-03

IC Document Collections

IC ID	Document Title	Status
45499	Medicare Part B Income-Related Premium -- Life-Changing Event (screen shots) Form	New
45497	Medicare Part B Income-Related Premium -- Life-Changing Event (paper form) Form and Instruction	New

ICR Details

OMB Control No: 0960-0735	ICR Reference No: 200609-0960-030
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: Medicare Part B Income-Related Premium -- Life-Changing Event
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/20/2006
	Date Received in OIRA: 10/03/2006
Terms of Clearance: This IC package is approved on the condition that it is updated annually to reflect, for example, changes in IRMAA premium amounts. Such non-substantive changes can be made through a change request, but any substantive changes will require a revision request.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2009	36 Months From Approved
Responses	76,100	0	0
Time Burden (Hours)	79,905	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Beginning in January 2007, as per MMA mandate, qualifying Medicare Part B beneficiaries will have to pay a new income-related monthly adjustment amount (IRMAA) which represents a reduction in their premiums. If beneficaries want to appeal SSA's determination of their IRMAA status due to reduced financial status caused by a recent Life-Changing Event, they can do so using new form SSA-44. The respondents are Medicare Part B beneficiaries wanting SSA to make a revised or new determination of their IRMAA status due to a recent life-changing event.

---

Authorizing Statute(s): PL: Pub.L. 108 - 173 811 Name of Law: Medicare Modernization Act of 2003
   US Code: 42 USC 1395r Name of Law: Social Security Act
  

Citations for New Statutory Requirements: PL: Pub.L. 108 - 173 811 Name of Law: Medicare Modernization Act of 2003

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 43270	07/31/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 58041	10/02/2006
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Medicare Part B Income-Related Premium -- Life-Changing Event (screen shots)	SSA-44 (electronic SSA-view screen shots)	Medicare Part B Income-Related Premium -- Life-Changing Event
Medicare Part B Income-Related Premium -- Life-Changing Event (paper form)	SSA-44	Medicare Part B Income-Related Premium - Life Changing Event

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	76,100	0	76,100	0	0	0
Annual Time Burden (Hours)	79,905	0	79,905	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: These burden increases are due to new Medicare Part B requirements imposed by the Medicare Modernization Act of 2003.

---

Annual Cost to Federal Government: $3,419,173

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/03/2006

---