Supporting Statement 0729

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 PART D) (RENEWAL)

20 CFR 418.3420

OMB No. 0960-0729

A. Justification

1. 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 subsidies be provided for those individuals who qualify for the program and who meet eligibility criteria for help with premium, deductible, and/or co-payment costs.

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 will verify applicants’ 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 applicants to contact their financial institutions (FI) to verify the reported account balances. SSA uses Form SSA-4640 to accomplish both of these processes.

2. SSA use Form SSA-4640 to obtain the individual’s authorization to verify balances of FI accounts and to obtain verification of such balances from the FI.

3. Due to the nature of the form, which requires written signatures/authorizations from two parties (the claimant and the financial institution) on the same form, SSA does not plan to implement an electronic version of this form.

4. The nature of the information we are collecting and the manner in which we are collecting 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 financial institution data for the Supplemental Security Income (SSI) program, that form is specific to the needs of the SSI program and requests more detailed information than is needed for the low-income subsidy (e.g., monthly account balances). Further, individuals who are eligible for SSI are automatically deemed eligible for the low-income subsidy, so there is no danger of the same beneficiary having to complete both forms.

5. This collection has a minimum impact on small businesses or other small entities.

6. If SSA did not collect the information, we would be unable to verify an individual’s eligibility or continued eligibility under the Medicare Quality Review System. Because the information will only be collected as needed, the information collection cannot be conducted less frequently.

There are no technical or legal obstacles that prevent burden reduction.

7. There are no special circumstances that would cause SSA to collect this information in a manner inconsistent with 5 CFR 1320.5.

8. SSA published the 60-day Federal Register Notice on February 17, 2009, at 74 FR 7506, and we received no public comments. We published the 30-day Federal Register Notice on April 24, 2009 at 74 FR 18782. There have been no outside consultations with members of the public.

9. SSA provides no payment or gifts to the respondents.

10. SSA is protects and holds confidential the information from this form 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.

11. The information collection does not contain any questions of a sensitive nature.

12. Below is the annual reporting burden for this form. The total burden represents burden hours, and we did not calculate a separate cost burden.

	Medicare Part D Subsidy Applicants	Financial Institutions	Totals
Number of Respondents	5,000	5,000	10,000
Average Burden Per Response (minutes)	1	4	5
Estimated Annual Burden (hours)	83	333	416

13. There is no known cost burden to the respondents.

14. The annual cost to the Federal Government for conducting this collection is approximately $2,200. This estimate is a projection of the costs for printing and distributing the collection instrument and for collecting the information.

15. The public reporting burden decreased from 833 hours to 416 hours. The decrease is due to a reduction in the number of respondents from 20,000 to 10,000, due to a large number of applicants at the beginning of the Medicare Part D Program’s Application for Help with Medicare Prescription Drug Plan Costs initiative in 2006. Further, prior to ROCIS we could not show the separate breakdown of respondents. Although there is only one form, there are two defferent groups of respondents (claimants and FIs) complete the same form.

16. SSA will not publish the results of the information collection.

17. OMB exempted SSA from publishing the expiration date for OMB approval on its forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB clearance. SSA does not periodically revise and reprint its public-use forms, (e.g., on an annual basis). OMB granted this exemption so that SSA would not have to stop using otherwise useable editions of forms with outdated expiration dates. In addition, we avoid government waste because we do not have to destroy and reprint stocks of forms.

18. 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.