Request for Hearing By Administrative Law Judge, 20 CFR 404.929, 404.933, 416.1429, 404.1433, 405.722, 418.1350

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form HA-501 Request for Hearing By Administrative Law Judge, 20 CFR 404.933, 20 CFR 405.722	Form and Instruction	Modified	Available
10-19-06 emergency 0960-0269 letter(3).doc	Supplementary Document	Uploaded 2006-10-19	Available
10-19-06 0960-0269 emergency supporting statement.doc	Supporting Statement A	Uploaded 2006-10-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9174	Request for Hearing By Administrative Law Judge, 20 CFR 404.933, 20 CFR 405.722	Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0269	ICR Reference No: 200610-0960-001
Status: Historical Active	Previous ICR Reference No: 200411-0960-006
Agency/Subagency: SSA	Agency Tracking No:
Title: Request for Hearing By Administrative Law Judge, 20 CFR 404.929, 404.933, 416.1429, 404.1433, 405.722, 418.1350
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 11/02/2006
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/22/2006
	Date Received in OIRA: 10/19/2006
Terms of Clearance: This emergency ICR is approved on the following conditions: 1) SSA will immediately begin work to update the form so that it is applicable to HHS ALJs and will print these new forms after the full ICR has been approved; 2)within 30 days after approval is granted, SSA will publish a 60-day FR notice and begin the process for a full ICR; 3)SSA will keep track of burden and update as necessary

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2007	6 Months From Approved	01/31/2008
Responses	669,469	0	667,236
Time Burden (Hours)	111,578	0	111,206
Cost Burden (Dollars)	0	0	0

---

Abstract: SSA uses form HA-501 to document when applicants for Social Security benefits have their claims denied and want to request an administrative hearing to appeal SSA’s decision. The scope of this form is now being expanded to include people who wish to appeal the decision that has been made regarding their obligation to pay a new Income-Related Monthly Adjustment Amount (IRMAA) for Medicare Part B, as per the requirements of the Medicare Modernization Act of 2003. Although this information will be collected by SSA, the actual hearings will take place before administrative law judges (ALJ) who are employed by the Department of Health and Human Services (HHS). The current respondents include applicants for various Social Security benefits programs who want to request a hearing where they can appeal their denial; the new additional respondents are Medicare Part B recipients whom SSA has determined will have to pay the new Medicare Part B IRMAA and who wish to appeal this decision at a hearing before an HHS ALJ.

Emergency Justfication: SSA is re-clearing this form to use it for Medicare Part B appeals. As per Rachel Potter's instructions, we are requesting re-clearance on an emergency basis because of time constraints. Please see attached letter which gives a detailed justification for this request.

---

Authorizing Statute(s): PL: Pub.L. 108 - 173 1350 Name of Law: Medicare Modernization Act of 2003
  

Citations for New Statutory Requirements: PL: Pub.L. 108 - 173 1350 Name of Law: Medicare Modernization Act of 2003

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 61820	10/19/2006
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Request for Hearing By Administrative Law Judge, 20 CFR 404.933, 20 CFR 405.722	HA-501	Request for Hearing by Administrative Law Judge

---

ICR Summary of Burden

table that charts list 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	669,469	667,236	2,233	0	0	0
Annual Time Burden (Hours)	111,578	111,206	372	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: Increase in burden is due to the additional number of respondents who will now use this form for Medicare Part B appeals.

---

Annual Cost to Federal Government: $1,050,000

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 10/19/2006

---