Supporting Statement 0960-0707

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. Introduction/Authoring Laws and Regulations - 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.

2. Description of Collection - SSA uses the 11 information collection tools in this Information Collection Request 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 Appointment-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 we already know and thus, we can pre-schedule the call.

3. SSA-9303: Notice of Appointment-Please Call Reviewer - 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 need to have available 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, SSA-9303, SSA-9311, SSA-9312, SSA-9313, and SSA-9314.

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-Redetermination-Reviewer Will Call - 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 Appointment-Redetermination-Please Call Reviewer - 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 for 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 SSA-1020, OMB No. 0960-0696.

3. Use of Information Technology to Collect the Information - 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. Why We Cannot Use Duplicate Information - 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. Minimizing Burden on Small Respondents – This collection does not affect small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently –

If SSA did not collect this information, we 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. Special Circumstances - There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public - SSA published the 60-day Federal Register Notice for form on November 7, 2011 at 76 FR 68805, and we did not receive any public comments. We published the 30-day Federal Register Notice on January 13, 2012 at 77 FR 2114. 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.

10. Assurances of Confidentiality - SSA protects and holds confidential the information we are collecting 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 Sensitive Questions - The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden - 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 Total Annual Burden (hours)
SSA-9301 (Medicare Subsidy Quality Review Case Analysis Questionnaire)	3,500	1	30	1,750
SSA-9302 (Notice of Appointment-Reviewer Will Call)	3,500	1	15	875
SSA-9303 (Notice of Appointment-Please Call Reviewer)	350	1	15	88
SSA-9304 (Checklist of Required Information; burden accounted for with Forms SSA-9302, SSA-9303, SSA-9311, SSA-9312, SSA-9313, and SSA-9314)	-	-	-	-
SSA-9308 (Request for Information)	7,000	1	15	1,750
SSA-9310 (Request for Documents)	3,500	1	5	292
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-9313 (Notice of Appointment-Redetermination-Reviewer Will Call)	2,500	1	15	625
SSA-9314 (Notice of Appointment-Redetermination-Please Call Reviewer)	500	1	15	125
SSA-8510 (Authorization for the Social Security Administration to Obtain Personal Information)	3,500	1	5	292
Total	24,850	-	-	5,923

The total of 5,923 hours represents burden hours, and we did not calculate a separate cost burden.

13. Annual 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 $154,140. This estimate is a projection of the costs for printing and distributing the collection instruments and for conducting the quality review interviews.

15. Program Changes or Adjustments to the Information Collection Request - The decrease in burden is due to a reduction of cases reviewed.

16. Plans for Publication Information Collection Results - SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date - OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms, with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g. on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.

18. Exceptions to Certification Statement – 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.