0960-0707 (Medicare Quality Review) supporting statement

SUPPORTING STATEMENT FOR FORMS SSA-9301, -9302, -9303, -9304, -9308, -9310,

-9311, -9312,- 9313, -9314 -8510

MEDICARE SUBSIDY QUALITY REVIEW FORMS

20 CFR 418(b)(5)

OMB No. 0960-0707

A. Justification

1. 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. We base the subsidy redeterminations on beneficiaries’ answers to questions about categories such as household size, income and assets. Since applicants self-report this information using form OMB No. 0960-0696 (SSA-1020), the application form for the Part D subsidy, SSA needs a way to determine if the information 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 the required review/verification of select Part D subsidy recipients. In this system, SSA contacts a random sample of applicants for the Medicare Part D Subsidy and tells them to expect a phone call from the agency. During this phone call, SSA interviews applicants to confirm and perhaps expand on information they reported on form SSA-1020 OMB No. 0960-0696. As part of the Quality Review program, we may ask applicants to give written consent for SSA to contact financial institutions and other third parties to confirm information from applicants’ SSA-1020.

This ICR is for revised versions of select instruments from this collection. The new versions, which we will use, beginning in 2010, comply with Public Law 110-275, the Medicare Improvements for Patients and Providers Act of 2008. The respondents are current recipients of the Medicare Part D low-income subsidy who will undergo an eligibility redetermination.

2. How, By Whom, and For What Purpose the Information Will Be Used.

SSA uses the eleven information collection tools in this ICR 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. We list and describe the information collection tools below:

1. SSA-9301: Medicare Subsidy Quality Review Case Analysis Questionnaire. This is the telephone questionnaire SSA employees administer to applicants for the Medicare Part D Subsidy. It includes questions about the applicant’s family size, marital status, income, assets, etc.

2. 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 for applicants whose phone numbers are known to the Agency and thus, we can pre-schedule the call.

3. SSA-9303: Notice of Quality Review Acknowledgement Form (unknown phone numbers). This form is similar to form SSA-9302, except it is for participants who do not have phones or whose phone numbers are unknown to SSA. On this form, participants confirm receipt of the letter and are asked to call SSA on a specified date.

4. SSA-9304: Checklist of Required Information. This checklist, which accompanies forms SSA-9302, SSA-9303, SSA-9311, SSA-9312, SSA-9313 and SSA-9314, is a list of the documentation respondents are supposed to have prepared when SSA calls them to conduct the Quality Review phone interview. We account for the burden for this checklist in the burdens for forms SSA-9302 and SSA-9303.

5. SSA-9308: Request for Information. SSA sends this form to various third parties (e.g., businesses besides insurance companies) to obtain or confirm information reported by applicants for the Part D subsidy.

6. 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.

7. 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 for applicants whose phone numbers are known to the Agency and thus, the call can be pre-scheduled. We tailored the language on this form for those Part D subsidy applicants with denied applications.

8. SSA-9312: Notice of Appointment-Denial-Please Call Reviewer. This form is similar to form SSA-9311, except it is for participants who do not have phones or whose phone numbers are unknown to 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.

9. 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 for beneficiaries whose phone numbers are known to the Agency and thus, we can pre-schedule the call.

10. SSA-9314: Notice of Quality Review Acknowledgement Form (unknown phone numbers). This form is similar to form SSA-9313, except it is for beneficiaries who do not have phones or whose phone numbers are unknown to SSA. On this form, beneficiaries confirm receipt of the letter and are asked to call SSA on a specified date.

11. 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.

3. 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 under the agency’s Government Paperwork Elimination Act plan is not relevant.

4. Describe Efforts to Identify Duplication.

The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to obtain similar data.

5. Discuss Whether and to What Extent the Collection Impacts Small Businesses.

This collection does not affect small businesses or other small entities.

6. Impact on Federal Program or Policy Activities if the Information Collection Was Not Conducted, Or if it was Conducted Less Frequently.

If SSA did not collect this information, SSA would be unable to conduct the mandatory verification of information reported in OMB No. 0960-0696. Because we will only conduct the Medicare Subsidy Quality Review process once per selected participant, we cannot conduct it less frequently.

There are no technical or legal obstacles to burden reduction.

7. Describe Any Special Circumstances Surrounding this Information Collection.

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Give the Dates of Publication for the Federal Register Notices, and Describe Any Public Comments Received in Response to Them.

SSA published the 60-day Federal Register Notice for form on October 28, 2008 at 73 FR 64004, and we did not receive any public comments. We published the 30-day Federal Register Notice on December 29, 2008 at 73 FR 79537. If we receive any comments in response to the 30-day Notice, we will forward them to OMB.

SSA did not consult with outside members of the public in the development or maintenance of this form.

9. Payment or Gifts to the Respondents.

SSA provides no payment or gifts to the respondents for completing this collection.

10. Assurances of Confidentiality.

SSA protects and holds confidential the information it is requesting 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.

11. Justification for Questions of a Sensitive Nature.

The information collection does not contain any questions of a sensitive nature.

12. Burden Information.

Below is a table with the number of respondents, completion time, and hourly burden information for the instruments in this collection.

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)	5,000	1	30 minutes	2,500 hours
SSA-9302 (Notice of Quality Review Acknowledgement Form for those with Phones)	5,000	1	15 minutes	1,250 hours
SSA-9303 (Notice of Quality Review Acknowledgement Form for those without Phones)	500	1	15 minutes	125 hours
SSA-9304 (Checklist of Required Information; burden accounted for with forms SSA-9302-, SSA-9303, SSA-9311-SSA-9314)	-	-	-	-
SSA-9308 (Request for Information)	10,000	1	15 minutes	2,500 hours
SSA-9310 (Request for Documents)	5,000	1	5 minutes	417 hours
SSA-9311 (Notice of Appointment – Denial –Reviewer Will Call)	450	1	15 minutes	113 hours
SSA-9312 (Notice of Appointment-Denial-Please Call Reviewer)	50	1	15 minutes	13 hours
SSA-8510 (Authorization to the Social Security Administration to Obtain Personal Information)	5,000	1	5 minutes	417 hours
SSA-9313 (Notice of Quality Review Acknowledgement Form for those with Phones)	2,500	1	15 minutes	625 hours
SSA-9314 (Notice of Quality Review Acknowledgement Form for those without Phones)	500	1	15 minutes	125 hours
Total	34,000 respondents	-	-	8,085 hours

The total of 8,085 hours represents burden hours, and we did not calculate a separate cost burden.

13. Cost to the Respondents.

There is no known cost burden to the respondents.

14. Cost to the Federal Government for Conducting the Collection.

The annual cost to the Federal Government for this collection is approximately $220,200. This estimate is a projection of the costs for printing and distributing the collection instruments and for conducting the quality review interviews.

15. Change in Reporting Burden.

The total burden decreased from 18,625 to 8,085 hours (a 10,540 hour decrease). This decrease is due to 1) a reduction in the number of respondents from 74,500 to 34,000, caused by the fact that there were a large number of SSA-1020 applicants at the beginning of the Medicare Part D program; 2) the elimination of certain questions, thus reducing the public reporting burden; and 3) the discontinuation of form SSA-9309, the Life Insurance Verification Form, which we no longer need (since applicants will not have to report the face value of their life insurance policies).

16. Publishing the Results of the Information Collection.

SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date.

OMB exempted SSA from the requirement to print the OMB approval date on its paper 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). Therefore, this exemption allows SSA to avoid destroying otherwise useable editions of forms with expired OMB approval dates, eliminating Government waste.

18. 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).

2. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.

0960-0707 supporting statement 2008

12/10/2010

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