Appeal of Determination for Help with Medicare Prescription Drug Plan Costs

Forms and Documents

Document	Type	Status	Availability
supporting statement 0695.doc	Supporting Statement A	Uploaded 2010-11-29	Available
Addendum.doc	Supplementary Document	Uploaded 2010-10-25	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
9749	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs	Other-Screens used by SSA employees for completion during person	Modified

ICR Details

OMB Control No: 0960-0695	ICR Reference No: 201007-0960-004
Status: Historical Active	Previous ICR Reference No: 200908-0960-012
Agency/Subagency: SSA	Agency Tracking No:
Title: Appeal of Determination for Help with Medicare Prescription Drug Plan Costs
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/08/2011
	Date Received in OIRA: 12/10/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2014	36 Months From Approved	04/30/2011
Responses	75,000	0	75,000
Time Burden (Hours)	12,500	0	12,500
Cost Burden (Dollars)	0	0	0

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Abstract: Medicare Part D is a voluntary prescription drug coverage program. In some cases, subsidization of premium, deductible, and co-payment costs for certain individuals is available. Form SSA-1021 is used to obtain information from individuals who appeal SSA's subsidy decisions. The respondents are individuals who wish to appeal the decision SSA has made regarding their eligibility for subsidization of Medicare Part D-related costs.

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Authorizing Statute(s): US Code: 42 USC 1395w-101 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:
	75 FR 45190	08/02/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 71785	11/24/2010
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Appeal of Determination for Help with Medicare Prescription Drug Plan Costs	SSA-1021	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs

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ICR Summary 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	75,000	75,000	0	0	0	0
Annual Time Burden (Hours)	12,500	12,500	0	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:

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Annual Cost to Federal Government: $30,680

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]? No

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: 12/10/2010

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