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
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. Section 1860D-14(a)(3) of the Social Security Act, as amended, allows us to collect this information.
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. The respondents are subsidy applicants or claimants and their financial institutions.
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 of Form SSA-4640 under the agency’s Government Paperwork Elimination Act (GPEA) plan. In addition, only 10,000 respondents complete the form annually. This is less than the GPEA cut-off of 50,000.
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.
Minimizing Burden on Small Respondents
This collection does not significantly affect small businesses or other small entities.
Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Form SSA-4640, we would be unable to verify an individual’s eligibility, or continuing eligibility, under the Medicare Quality Review System. Because we only collect this information as needed, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.
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.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on March 21, 2018, at
83 FR 12455, and we received no public comments. The 30-day FRN published on June 8, 2018 at 83 FR 26736. If we receive any comments in response to this Notice, we will forward them to OMB.
Payment or Gifts to Respondents
SSA does not provide payment or gifts to the respondents.
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.
Justification for Sensitive Questions
This information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Modality of Completion |
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. We based these figures on current management information data. We did not calculate a separate cost burden.
Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden on the respondents.
Annual Cost to Federal Government
The annual cost to the Federal Government is approximately $5,800. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; and (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time.
Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
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.
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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Part D Subsidy App SUPPORTING STATEMENT INSTRUCTIONS FOR FORM __________ |
| Author | 762320 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |