Medicare Part B Income-Related Premium -- Life-Changing Event

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-44 Medicare Part B Income-Related Premium -- Life-Changing Event (paper form)	Form and Instruction	Modified	Available
SSA-44 (0960-0735) addendum 2010 (emergency).doc	Supplementary Document	Uploaded 2010-06-29	Available
SSA-44 (0960-0735) emergency request clearance letter.doc	Supplementary Document	Uploaded 2010-06-29	Available
SSA-44 (0960-0735) emergency supporting statement.doc	Supporting Statement A	Uploaded 2010-06-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
45499	Medicare Part B Income-Related Premium -- Life-Changing Event (screen shots)	Other-MSSICS Screens	Modified
45497	Medicare Part B Income-Related Premium -- Life-Changing Event (paper form)	Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0735	ICR Reference No: 201006-0960-013
Status: Historical Active	Previous ICR Reference No: 200906-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Medicare Part B Income-Related Premium -- Life-Changing Event
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 07/06/2010
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/07/2010
	Date Received in OIRA: 06/29/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2011	6 Months From Approved	11/30/2012
Responses	176,000	0	160,000
Time Burden (Hours)	97,250	0	88,000
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses the information collected by form SSA-44 to determine if the initial IRS tax data used for the beneficiary is up-to-date. If the agency determines the LCE has significantly reduced the beneficiary’s income, it will use the information to update its original determinations or to make new initial determinations. The respondents are Medicare part B enrollees with modified adjusted gross income over an established high-income “threshold.” In this emergency ICR, we are requesting minor changes to the form to conform with soon-to-be-published regulations.

Emergency Justfication: In several weeks, SSA plans to publish regulations at RIN 0960-AH06 (docket no. SSA-2009-0078). These rules will expand the definition of property loss and will add a new life-changing event: receipt of a one-time employer’s settlement payment. We will revise form SSA-44 to include the expanded and new LCEs. The attached Supporting Statement and Addendum to the Supporting Statement outline the specific changes we are making. Because these new rules will be effective on publication, we must have the revised form in place by the time they publish. We are therefore requesting emergency clearance one week from today, Tuesday, July 6, 2010. See attached Emergency Request Letter for further details. A copy of the soon-to-be-published rules is also attached.

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Authorizing Statute(s): US Code: 42 USC 1395r Name of Law: Social Security Act
  

Citations for New Statutory Requirements: PL: Pub.L. 108 - 173 811 Name of Law: Medicare Modernization Act of 2003

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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:
	75 FR 37518	06/29/2010
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
Medicare Part B Income-Related Premium -- Life-Changing Event (paper form)	SSA-44	Medicare Part B Income-Related Premium - Life-Changing Event
Medicare Part B Income-Related Premium -- Life-Changing Event (screen shots)

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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	176,000	160,000	16,000	0	0	0
Annual Time Burden (Hours)	97,250	88,000	9,250	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: SSA anticipates an increase in burden hours due to a slight increase of the number of requests we will received based on the revised regulation.

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Annual Cost to Federal Government: $8,419,173

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]? No

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)? No

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: 06/29/2010

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