SUPPORTING STATEMENT FOR FORM SSA-604
CERTIFICATE OF INCAPACITY
5 CFR 890.302(d)
OMB No. 0960-NEW
A. Justification
The Federal Employee Health Benefits (FEHB) Program allows dependent children of Federal employees to continue receiving health care benefits as covered family members until age 22. At 22, children are automatically terminated from the Federal employee’s coverage.
However, as per section 5 CFR 890.302(d) of the Code of Federal Regulations, children ages 22 and older can continue to receive health benefits under the FEHB if they are incapable of self-support due to a disability that 1) pre-dated the child’s 22nd birthday, 2) is very serious, and 3) can be expected to last at least one year.
Section 5 CFR 890.302(d) states that in order for federal employees’ children ages 22 or over to qualify for the FEHB, their physician must verify that they have a disability which meets the three criteria cited above. Form SSA-604, the Certificate of Incapacity, is used for this purpose by physicians of children ages 22 and over whose parents are employees of the Social Security Administration (SSA).
This form asks physicians to describe the child’s disability and to certify that it meets the criteria cited above. The completed form is then used by SSA’s physicians to evaluate the child’s case and determine if the child is still eligible for coverage of health benefits under the FEHB.
This information collection will not be implemented under the Agency’s Government Paperwork Elimination Act plan due to the extremely low number of respondents (38 per year). However, please note that the form is only available as a print-only PDF on SSA’s website, which is a cost-saving measure for the Agency.
The nature of the information being collected and the manner in which it is collected preclude duplication. There is no other collection instrument used by SSA that collects data similar to that collected here.
This collection does not significantly impact small businesses or other small entities.
If this information were not collected, SSA employees with children ages 22 and over who qualify for the FEHB program because of their disabilities would have no means of applying to retain their health coverage. Because the form is only completed once by a physician, the information cannot be collected less frequently.
There are no technical or legal obstacles that prevent burden reduction.
There are no special circumstances that would cause this information collection to be conducted in a manner inconsistent with 5 CFR 1320.5.
The advance 60-day Federal Register Notice for this collection was published on May 26, 2006 at 71 FR 30464, and no public comments were received. The 30-day Federal Register Notice was published on August 8, 2006 at 71 FR 45090. We will notify OMB if any public comments are submitted in response to this Notice.
There have been no outside consultations with members of the public.
SSA provides no payment or gifts to the respondents.
The information requested is protected and held confidential 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.
The information collection does not contain any questions of a sensitive nature.
An estimated 38 physicians take 45 minutes each to complete form SSA-604 each year, resulting in a burden of 29 hours. The total burden is reflected as burden hours, and no separate cost burden has been calculated.
There is no known cost burden to the respondents.
The annual cost to the Federal Government is approximately $1,964.22. This cost is an estimate of the fees paid to SSA physicians for reviewing the form.
This information collection has been in existence for some time as a “bootleg form” - i.e., it was not OMB-approved. Therefore, although it is not new, it will increase the public reporting burden by 29 hours.
The results of the information collection will not be published.
We are requesting an exemption from publishing the expiration date on this PDF-only form. The reason for this exemption is that we have some operational problems with placing the OMB expiration date on PDF versions of forms, and issue which we are researching and which we intend to address in the near future.
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).
Collections of Information Employing Statistical Methods
Statistical methods are not used for this information collection.
SSA-604
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR FORM SSA-604 |
| Author | Faye |
| Last Modified By | Davidson, Liz |
| File Modified | 2006-09-12 |
| File Created | 2006-09-12 |