SUPPORTING STATEMENT FOR FORM SSA-1021
APPEAL OF DETERMINATION FOR HELP WITH MEDICARE PRESCRIPTION
DRUG PLAN COSTS
20 CFR 418.3110
OMB No. 0960-0695
A. Justification
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) established a Medicare Part D program for voluntary prescription drug coverage of premium, deductible, and co-payment costs for certain low-income individuals. The MMA mandates that subsidies be provided for those individuals who qualify for the program and who meet eligibility criteria for help with premium, deductible, and/or co-payment costs.
The Social Security Administration (SSA) uses form SSA-1020 (OMB No. 0960-0696) to collect information and make a subsidy eligibility determination. Section 1631(c)(1)(A) of the Social Security Act, as codified by 20 CFR 418.3110 of the Code of Federal Regulations, describes the right of beneficiaries to appeal SSA’s eligibility determination. The latter section describes the appeal/administrative review process, in which individuals may request a reconsideration hearing via phone, mail, or e-mail. This hearing will be conducted by telephone or, if the individual waives this option, SSA will conduct a case review. If the individual does not agree with the outcome of the reconsideration hearing/case review, the individual may appeal to a Federal district court.
SSA requires an instrument which individuals can use to request an appeal by mail. Form SSA-1021, the Appeal of Determination for Help with Medicare Prescription Drug Plan Costs, will be used for this purpose.
Form SSA-1021 is used by individuals to request an appeal of SSA’s determination about their eligibility for a Medicare Part D subsidy.
Currently, no electronic version of form SSA-1021 is available under the Agency’s Government Paperwork Elimination Act plan due to its short length and the lack of interest from respondents. We will consider electronic versions in the future if respondents begin to express an interest. SSA employees can use an internal electronic system, the Medicare Application Processing System (MAPS), for beneficiaries who want to complete the form via an in-person interview. However, this is not a true electronic form since only SSA employees can access it and it does not impact the burden for this ICR.
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.
This collection does not impact small businesses or other small entities.
If this form were not used, individuals wishing to appeal in writing SSA’s Medicare Part D subsidy eligibility determinations for them would be unable to do so, which would be a violation of the MMA. Because the form is only completed when individuals appeal their subsidy eligibility determination, the information cannot be collected less frequently.
There are no technical or legal obstacles that prevent burden reduction.
There are no special circumstances that would cause this information collection to be conducted in a manner inconsistent with 5 CFR 1320.5.
The 60-day advance Federal Register Notice for this collection published on September 14, 2007, at 72 FR 52594, and there were no public comments. The 30-day Federal Register Notice published on November 30, 2007, at 72 FR 67776. We will forward any public comments we receive in response to the second Notice to OMB.
There have been no consultations with members of the public.
SSA provides no payment or gift to the respondents.
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.
The information collection does not contain any questions of a sensitive nature.
Form SSA‑1021 will be completed by approximately 75,000 respondents annually. The estimated form completion time is 10 minutes, for a total of 12,500 burden hours. The total burden is reflected as burden hours, and no separate cost burden has been calculated.
There is no known cost burden to the respondents.
The annual cost to the Federal Government is approximately $30,680. This estimate is a projection of the costs for printing and distributing the collection instrument.
There are no changes in the public reporting burden.
The results of the information collection will not be published.
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.
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 for the collection of information are not used.
OMB No. 0960-0695 (SSA-1021)
| File Type | application/msword |
| File Title | Supporting Statement for Form SSA-1021 |
| Author | Diane Swift |
| Last Modified By | 666429 |
| File Modified | 2007-12-06 |
| File Created | 2007-11-06 |