SUPPORTING STATEMENT FOR FORMS SSA-9301, -9302, -9303, -9304, -9308, -9309, -9310,
-9311, -9312, -8510 (RENEWAL),
and SSA-9313 and -9314 (NEW)
MEDICARE SUBSIDY QUALITY REVIEW FORMS
20 CFR 418(b)(5)
OMB No. 0960-0707
A. Justification
Circumstances Which Make the Information Collection Necessary and Legal Justification for the Collection.
Under the aegis of the Medicare Modernization Act of 2003, the Social Security Administration (SSA) makes Medicare Part D subsidy redeterminations of continued eligibility. The subsidy redetermination is based on beneficiaries’ answers to questions about categories such as household size, income and assets. Since this information is self-reported by applicants using form OMB No. 0960-0696 (SSA-1020), the application form for the Part D subsidy, SSA needs a way to determine if it is accurate and complete, as per section 1860 D-14(a)(3)(E)(iii)(III) of the Social Security Act and section 20 CFR 418(b)(5) of the Code of Federal Regulations.
Since August 2005, SSA has used 0960-0707, the Medicare Subsidy Quality Review Case Analysis system, to conduct its required review/verification of select Part D subsidy recipients. In this system, a random sample of applicants for the Medicare Part D Subsidy is contacted by SSA and is told to expect a phone call from the Agency. During this phone call, applicants are interviewed to confirm and perhaps expand on information they reported on form SSA-1020 OMB No. 0960-0696. As part of the Quality Review program, applicants may be asked to give written consent for SSA to contact insurance companies and other third parties to confirm information from applicants’ SSA-1020.
The Agency is planning to expand the scope of 0960-0707 by conducting Quality Reviews with selected current recipients of Medicare Part D subsidies who have recently undergone the redetermination process (under OMB No. 0960-0723). This ICR is for clearance of two new forms for this expanded scope: form SSA-9313, the Notice of Appointment Quality Review Acknowledgement Form (for those with known phone numbers) and form SSA-9314, the Notice of Appointment Quality Review – Please Call Reviewer (for those beneficiaries with unknown phone numbers). Please note the actual Quality Review script used for these beneficiaries will be the SSA-9301, which is the same one used for the other beneficiaries covered by 0960-0707.
How, By Whom, and For What Purpose the Information Will Be Used.
The eight current information collection tools in this ICR are used by the Agency to conduct the Medicare Subsidy Quality Review. The purpose of these tools is to help the Agency confirm the information reported on form SSA-1020 and to validate its Medicare Part D subsidy determinations. The information collection tools are listed and described below:
SSA-9301: Medicare Subsidy Quality Review Case Analysis Questionnaire. This is the telephone questionnaire which is administered by SSA employees to applicants for the Medicare Part D Subsidy. It includes questions about the applicant’s family size, marital status, income, assets, etc.
SSA-9302: Notice of Quality Review Acknowledgement Form. After receiving notice of the scheduled date/time of the telephone questionnaire, Part D applicants return this form confirming their availability for the interview and making note of any special needs for the call. This version is used by applicants whose phone numbers are known to the Agency and thus, the call can be pre-scheduled.
SSA-9303: Notice of Quality Review Acknowledgement Form (unknown phone numbers). This form is similar to form SSA-9302, except it is used by participants who do not have phones or whose phone numbers are not known by SSA. On this form, participants confirm receipt of the letter and are asked to call SSA on a specified date.
SSA-9304: Checklist of Required Information. This checklist, which accompanies forms SSA-9302 and SSA-9303, is a list of the documentation respondents are supposed to have prepared when SSA calls them to conduct the Quality Review phone interview. The burden for this checklist is accounted for in the burdens for forms SSA-9302 and SSA-9303.
SSA-9308: Request for Information. This form is sent by SSA to various third parties (e.g., businesses besides insurance companies) to obtain or confirm information reported by applicants for the Part D subsidy.
SSA-9310: Request for Documents. Following the phone interview, SSA sends this notice to the applicants advising them of the documents they must return to SSA.
SSA-9309: Life Insurance Verification Form. Insurance companies complete this form to confirm the type, face value, cash surrender value, and dividends for insurance policies reported by applicants for the subsidy.
SSA-9311: Notice of Appointment – Denial –Reviewer Will Call. After receiving notice of the scheduled date/time of the telephone questionnaire, Part D applicants return this form confirming their availability for the interview and making note of any special needs for the call. This version is used by applicants whose phone numbers are known to the Agency and thus, the call can be pre-scheduled. The language on this form is tailored for those Part D subsidy applicants whose applications were denied.
SSA-9312: Notice of Appointment-Denial-Please Call Reviewer. This form is similar to form SSA-9311, except it is used by participants who do not have phones or whose phone numbers are not known by SSA. On this form, participants confirm receipt of the letter and are asked to call SSA on a specified date. This form is also designed for Part D subsidy applicants whose applications were denied.
SSA-8510: Authorization to the Social Security Administration to Obtain Personal Information. Applicants for the Part D subsidy will complete this form, authorizing SSA to contact third parties to confirm information reported on form OMB No. 0960-0696.
Two new information collection tools, forms SSA-9313 and SSA-9314, will be used by the Agency to set up telephone appointments for the Quality Review of Medicare Subsidy cases in which a beneficiary had a redetermination for the Medicare Part D subsidy award. These telephone appointments help the Agency confirm the information reported in the redetermination process (OMB No. 0960-0723) and validate its Medicare Part D subsidy redeterminations. A description of these forms follows:
SSA-9313: Notice of Appointment Quality Review Acknowledgement Form. After receiving notice of the scheduled date and time of the telephone interview, Part D beneficiaries return this form confirming their availability for the interview and making note of any special needs for the call. This version is used by beneficiaries whose phone numbers are known to the Agency and thus, the call can be pre-scheduled.
SSA-9314: Notice of Quality Review Acknowledgement Form (unknown phone numbers). This form is similar to form SSA-9313, except it is used by beneficiaries who do not have phones or whose phone numbers are not known by SSA. On this form, beneficiaries confirm receipt of the letter and are asked to call SSA on a specified date.
Describe To What Extent the Information Collections Involve the Use of Electronic Technology.
Due to the nature of this collection (i.e. telephone interviews and notification of these appointments), electronic implementation is not relevant.
Describe Efforts to Identify Duplication.
The nature of the information being collected and the manner in which it is collected preclude duplication. There is no other collection instrument used by SSA that collects data similar to that collected here.
Discuss Whether and to What Extent the Collection Impacts Small Businesses.
This collection does significantly impact small businesses or other small entities.
Impact on Federal Program or Policy Activities if the Information Collection Was Not Conducted, Or if it Was Conducted Less Frequently.
If this information were not collected, SSA would not be able to set up the telephone appointments to conduct the mandatory verification of information reported in OMB No. 0960-0696 or 0960-0723 forms. Because the Medicare Subsidy Quality Review process (both for 0960-0696 applicants and 0960-0723 redetermination subjects) will only be conducted once per selected participant, it cannot be conducted less frequently.
There are no technical or legal obstacles that prevent burden reduction.
Describe Any Special Circumstances Surrounding this Information Collection.
There are no special circumstances that would cause this information collection to be conducted in a manner inconsistent with 5 CFR 1320.5.
Give the Dates of Publication for the Federal Register Notices, and Describe Any Public Comments Received in Response to Them.
The 60-day Advance Federal Register Notice for this collection was published on May 21, 2007 at 72 FR 28543, and SSA has not received any public comments. The 30-day Advance Federal Register Notice was published on Friday, August 10, 2007, at 72 FR 45079. Following publication of the 30-day Notice, we realized that we had inadvertently omitted two forms which were already cleared as part of this ICR. To correct this omission, we published a correction 30-day Notice on September 14, 2007 at 72 FR 52594. SSA will forward any public comments received in response to that Notice.
There have been no outside consultations with members of the public.
Payment or Gifts to the Respondents.
SSA provides no payment or gifts to the respondents for completing this collection.
Assurances of Confidentiality.
The information requested is protected and held confidential in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.
Justification for Questions of a Sensitive Nature.
The information collection does not contain any questions of a sensitive nature.
Burden Information.
Below is a table with the number of respondents, completion time, and hourly burden information for the instruments in this collection. The total burden of 1,250 hours is reflected as burden hours, and no separate cost burden has been calculated.
Form Number and Name |
Number of Respondents |
Frequency of Response |
Average Burden Per Response (minutes) |
Estimated Annual Burden (hours) |
SSA-9301 (Medicare Subsidy Quality Review Case Analysis Questionnaire)
|
10,000 |
1 |
35 minutes |
5,833 hours |
SSA-9302 (Notice of Quality Review Acknowledgement Form for those with Phones) |
10,000 |
1 |
15 minutes |
2,500 hours |
SSA-9303 (Notice of Quality Review Acknowledgement Form for those without Phones) |
1,000 |
1 |
15 minutes |
250 hours |
SSA-9304 (Checklist of Required Information; burden accounted for with forms SSA-9302, SSA-9303) |
- |
- |
- |
- |
SSA-9308 (Request for Information) |
20,000 |
1 |
15 minutes |
5,000 hours |
SSA-9310 (Request for Documents) |
10,000 |
1 |
5 minutes |
833 hours |
SSA-9309 (Life Insurance Verification Form) |
8,000 |
1 |
15 minutes |
2,000 hours |
SSA-9311 (Notice of Appointment – Denial –Reviewer Will Call)
|
450 |
1 |
15 |
113 |
SSA-9312 (Notice of Appointment-Denial-Please Call Reviewer)
|
50 |
1 |
15 |
13 |
SSA-8510 (Authorization to the Social Security Administration to Obtain Personal Information) |
10,000 |
1 |
5 minutes |
833 hours |
SSA-9313 (Notice of Quality Review Acknowledgement Form for those with Phones) |
4,500 |
1 |
15 minutes |
1,125 hours |
SSA-9314 (Notice of Quality Review Acknowledgement Form for those without Phones) |
500 |
1 |
15 minutes |
125 hours |
Total |
74,500 respondents |
- |
- |
18,625 hours |
The total burden is 18,625 hours. The total burden is reflected as burden hours, and no separate cost burden has been calculated.
Cost to the Respondents.
There is no known cost burden to the respondents.
Cost to the Federal Government for Conducting the Collection.
The annual cost to the Federal Government is approximately $507,213. This estimate is a projection of the costs for printing and distributing the collection instruments and for conducting the quality review interviews.
Change in Reporting Burden.
This is a new information collection that will increase the public reporting burden.
Publishing the Results of the Information Collection.
The results of the information collection will not be published.
Displaying the OMB Approval Expiration Date.
OMB has granted SSA an exemption from the requirement that the expiration date for OMB approval be printed on its program forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB approval. SSA does not periodically revise and reprint its public-use forms (e.g. on an annual basis). This exemption was granted so that otherwise useable editions of forms would not be taken out of circulation because the expiration date had been reached. In addition, Government waste has been avoided because stocks of forms will not have to be destroyed and reprinted.
Meeting Certification Provisions.
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).
B. Collections of Information Employing Statistical Methods
Statistical methods are not used for this information collection.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR FORMS SSA-9301, SSA-9302, SSA-9303, SSA-9304, SSA-9308, SSA-9309, SSA-9310, and SSA-8510 |
| Author | SME |
| Last Modified By | 666429 |
| File Modified | 2007-09-17 |
| File Created | 2007-07-25 |