Supporting Statement - 0729

Supporting Statement for Form SSA-4640

Authorization for the Social Security Administration to

Obtain Account Records from a Financial Institution and

Request for Records (Medicare)

20 CFR 418.3420

OMB No. 0960-0729

A. Justification

1. Introduction/Authoring Laws and Regulations

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) established the Medicare Part D program for voluntary prescription drug coverage of premium, deductible, and co-payment costs for individuals with limited income and resources. The MMA mandates that the Government provide subsidies for those individuals who qualify for the program, and who meet eligibility criteria for help with premium, deductible, or co-payment costs. SSA uses the SSA-4640, Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) to verify whether applicants and claimants meet eligibility criteria.

2. Description of Collection

To determine if subsidy applicants or recipients qualify or continue to qualify for the subsidy, the Social Security Administration (SSA) conducts quality reviews of selected applications under the Medicare Quality Review System (OMB No. 0960-0707). As part of the quality review, SSA verifies claimants’ reported financial accounts as discussed in section 20 CFR 418.3420 of the Code of Federal Regulations. To complete this verification, SSA needs to obtain authorization from claimants to contact their financial institutions (FI) to verify the reported account balances. SSA uses Form SSA-4640 to: (1) obtain the individual’s consent to verify balances of FI accounts, and (2) obtain verification of such balances from the FI. Respondents are subsidy applicants or claimants and their financial institutions.

3. Use of Information Technology to Collect the Information

Due to the nature of the form, which requires written signatures and authorizations from two parties (the subsidy claimant and the FI) on the same form, SSA does not currently have a plan to implement an electronic version under the agency’s Government Paperwork Elimination Act (GPEA) plan. In addition, due to the low volume of respondents for this form, which is below the GPEA cut-off of 50,000, higher volume forms take precedence for electronic implementation.

4. Why We Cannot Use Duplicate Information

The nature of the information we collect and the manner in which we collect it preclude duplication. Although SSA uses a similar form (SSA-4641, Authorization for The Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records, OMB No. 0960-0293) to obtain FI data for the Supplemental Security Income (SSI) program, that form is specific to the needs of the SSI program. The SSA-4641 (0960‑0293) requests more detailed information than needed for the low-income Medicare subsidy (e.g., monthly account balances). Further, we automatically deem eligible-SSI individuals the low-income subsidy, so there is no danger of the same beneficiary completing both forms.

5. Minimizing Burden on Small Respondents

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

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

If SSA did not collect the information, we would be unable to verify an individual’s eligibility or continued eligibility under the Medicare Quality Review System. Because we only collect the information as needed, we cannot collect 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 advance Federal Register Notice on March 9, 2015 at 80 FR 12542, and we received no public comments. We published the 30-day Federal Register Notice on May 27, 2015 at 80 FR 30316. We did not consult with members of the public regarding this form.

9. Payment or Gifts to Respondents

SSA does not provide payment or gifts to the respondents.

10. Assurances of Confidentiality

SSA protects and holds confidential the information it collects 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

The chart below shows the burden per type of respondent:

Type of Respondent	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimate Total Annual Burden (hours)
Medicare Part D Subsidy Applicants	5,000	1	1	83
Financial Institutions	5,000	1	4	333
Totals	10,000			416

The total burden for this ICR is 416 hours. This figure represents burden hours and we did not calculate a separate cost burden

13. Annual Cost to the Respondents (Other)

This collection does not impose a known cost burden on the respondents.

14. Annual Cost to Federal Government

The annual cost to the Federal Government for conducting this collection is approximately $5,400. This estimate is a projection of the costs for printing and distributing the collection instrument, and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request

There are no changes to the public reporting burden.

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 that 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).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.