Medicare Subsidy Quality Review Case Analysis

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-8510 Authorization for the Social Security Administration to Obtain Personal Information	Form and Instruction	New	Available
Form SSA-9310 Request for Documents	Form and Instruction	New	Available
Form SSA-9309 Life Insurance Verification	Form and Instruction	New	Available
Form SSA-9308 Request for Release of Information	Form and Instruction	New	Available
Form SSA-9312 Notice of Appointment -Denial- Please Call Reviewer	Form and Instruction	New	Available
Form SSA-9311 Notice of Appointment -Denial- Reviewer Will Call	Form and Instruction	New	Available
Form SSA-9303 Notice of Appointment-Please Call Reviewer	Form and Instruction	New	Available
Form SSA-9302 Notice of Appointment - Reviewer Will Call	Form and Instruction	New	Available
0960-0707 summary of nonsubstantive changes.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2007-04-02	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9763	SSA-9301	Other-Question script used by SSA for phone interview	Modified
179417	SSA-8510	Form and Instruction	New	Authorization for the Social Security Administration to Obtain Personal Information
179416	SSA-9310	Form and Instruction	New	Request for Documents
179415	SSA-9309	Form and Instruction	New	Life Insurance Verification
179414	SSA-9308	Form and Instruction	New	Request for Release of Information
179412	SSA-9312	Form and Instruction	New	Notice of Appointment -Denial- Please Call Reviewer
179411	SSA-9311	Form and Instruction	New	Notice of Appointment -Denial- Reviewer Will Call
179409	SSA-9303	Instruction	New
179409	SSA-9303	Form and Instruction	New	Notice of Appointment-Please Call Reviewer
179406	SSA-9302	Instruction	New
179406	SSA-9302	Form and Instruction	New	Notice of Appointment - Reviewer Will Call

ICR Details

OMB Control No: 0960-0707	ICR Reference No: 200704-0960-001
Status: Historical Active	Previous ICR Reference No: 200602-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Medicare Subsidy Quality Review Case Analysis
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/17/2007
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/03/2007
Terms of Clearance: This ICR change is approved on the understanding that 1) the minor typos on form 8510, 9302, and 9303 will be fixed prior to fielding the instruments; 2) that no changes are being made to previously approved forms 8510, 9309, and 9310; and 3) that forms 9309, 9310, and 8510 will be used to collect information after the phone interview and that respondents will be aware that their completion of 8510, 9309, and 9310 are voluntary, just as their participation in the phone interview is voluntary.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2009	04/30/2009	04/30/2009
Responses	69,500	0	69,000
Time Burden (Hours)	17,375	0	17,249
Cost Burden (Dollars)	0	0	0

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Abstract: To validate the Medicare Part D subsidy determinations it is making, SSA uses the Medicare Subsidy Quality Review Case Analysis system, in which it calls selected applicants and insurance/other companies to confirm certain information reported on form SSA-1020 (OMB No. 0960-0696). The respondents are applicants for the Medicare Part D subsidy information, insurance companies, and other third parties. This submission is for nonsubstantive wording changes to several of the forms in this collection.

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Authorizing Statute(s): US Code: 42 USC 1395w-114
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
SSA-8510	SSA-8510	Authorization for the Social Security Administration to Obtain Personal Information
SSA-9301
SSA-9302	SSA-9302	Notice of Appointment - Reviewer Will Call
SSA-9303	SSA-9303	Notice of Appointment-Please Call Reviewer
SSA-9308	SSA-9308	Request for Release of Information
SSA-9309	SSA-9309	Life Insurance Verification
SSA-9310	SSA-9310	Request for Documents
SSA-9311	SSA-9311	Notice of Appointment -Denial- Reviewer Will Call
SSA-9312	SSA-9312	Notice of Appointment -Denial- Please Call Reviewer

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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	69,500	69,000	0	500	0	0
Annual Time Burden (Hours)	17,375	17,249	0	126	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Two new forms were added which increased the overall burden. While these forms a new, the scope of this collection has not changed. Also, there is no actual decrease in burden; it appears this way in ROCIS due to the way ROCIS transferred data from the original paper submission of this form, which predated ROCIS. NOTE: Please note that although the following forms are attached to this ICR change sheet request, they were not changed in any way from when they were first approved: forms SSA-9308, SSA-9309, SSA-9310, and SSA-8510.

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Annual Cost to Federal Government: $0

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

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Common Form ICR:  No

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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: 04/03/2007

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