Medicare Modernization Act Outreach Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-1023 MMA Outreach Mailer Insert (Form SSA-1023)	Form	New	Available
MMA Outreach Supporting Statement (0960-NEW).doc	Supporting Statement A	Uploaded 2008-06-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
185181	MMA Outreach Phone Call Script	Other-Phone Message	New
185180	MMA Outreach Mailer Insert (Form SSA-1023)	Form	New

ICR Details

OMB Control No: 0960-0773	ICR Reference No: 200806-0960-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: Medicare Modernization Act Outreach Program
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/15/2008
	Date Received in OIRA: 06/06/2008
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2011	36 Months From Approved
Responses	105,000	0	0
Time Burden (Hours)	1,750	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: To promote awareness of the Medicare Part D subsidy program and encourage potentially eligible Medicare beneficiaries to complete form SSA-1020 (OMB No. 0960-0696, the Application for Help with Medicare Prescription Drug Plan Costs), SSA plans to use a new outreach program. Pharmacies, doctors’ offices, and medical clinics will display and distribute copies of a brochure (which incorporates a mailer, form SSA-1023) to encourage eligible Medicare beneficiaries to request and complete form SSA 1020. The brochure will include an insert that beneficiaries complete to request form SSA-1020 from SSA. SSA will make follow-up phone calls to beneficiaries who use form SSA-1023 to request an application form (SSA-1020) but do not submit the SSA-1020 to the Agency. The respondents are Medicare beneficiaries who 1) are potentially eligible for Part D subsidy benefits and 2) request a copy of form SSA-1020 using form SSA-1023.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 0 Name of Law: Medicare Modernization Act of 2003
   US Code: 42 USC 405 Name of Law: Social Security Act
  

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
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 16087	03/26/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 31530	06/02/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
MMA Outreach Phone Call Script
MMA Outreach Mailer Insert (Form SSA-1023)	SSA-1023	MMA Outreach Mailer Insert

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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	105,000	0	0	105,000	0	0
Annual Time Burden (Hours)	1,750	0	0	1,750	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: No

Burden Reduction Due to:

Short Statement: This ICR increases the overall burden because it is a new outreach effort.

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Annual Cost to Federal Government: $180,348

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: 06/06/2008

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