Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event

Forms and Documents

Document Name	Status
Form SSA-44 Paper Form (mailed) Form and Instruction	Modified
Supporting Statement - 0784.docx Supporting Statement A	2011-05-24
Addendum - 0784.docx Supplementary Document	2011-05-24

IC Document Collections

IC ID	Document Title	Status
195114	Paper Form (mailed) Form and Instruction	Modified
195110	Personal Interview (SSA Field Office) Other-Intranet Screens	Modified

ICR Details

OMB Control No: 0960-0784	ICR Reference No: 201101-0960-005
Status: Historical Active	Previous ICR Reference No: 201011-0960-009
Agency/Subagency: SSA	Agency Tracking No:
Title: Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/29/2011
	Date Received in OIRA: 05/26/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2014	36 Months From Approved	07/31/2011
Responses	186,000	0	186,000
Time Burden (Hours)	102,750	0	102,750
Cost Burden (Dollars)	0	0	0

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Abstract: Per the Medicare Modernization Act of 2003, selected Medicare insurance recipients pay an income-related monthly adjustment amount (IRMAA). The Internal Revenue Service (IRS) transmits income tax return data to SSA for SSA to determine the amount of IRMAA. SSA will use the new Form SSA–44 to determine if a recipient qualifies for a reduction in IRMMA. If affected Medicare recipients believe SSA should use more recent tax data because a life-changing event occurred that significantly reduces their income, they can report these changes to SSA and ask for a new initial determination of their IRMAA. In this ICR, we are seeking full OMB approval for the collection which we cleared on an emergency basis several months ago.

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Authorizing Statute(s): US Code: 42 USC 1395r Name of Law: The Social Security Act
   US Code: 42 USC 1395w-104 Name of Law: The Social Security Act
   PL: Pub.L. 111 - 148 3308 Name of Law: The Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3308 Name of Law: The Patient Protection and Affordable Care Act

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 8394	02/14/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 28297	05/16/2011
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Paper Form (mailed)	SSA-44	Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event
Personal Interview (SSA Field Office)

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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	186,000	186,000	0	0	0	0
Annual Time Burden (Hours)	102,750	102,750	0	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:

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Annual Cost to Federal Government: $8,500,000

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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 05/26/2011

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