Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-44 Paper Form (mailed)	Form and Instruction	New	Available
SSA-44 - 07-2010.pdf	Supplementary Document	Uploaded 2010-11-04	Available
SSA-44 Letter to OMB requesting form replacement.docx	Supplementary Document	Uploaded 2010-11-16	Available
Addendum - SSA-44.docx	Supplementary Document	Uploaded 2010-11-17	Available
Supporting_Statement_-_SSA-44.docx	Supporting Statement A	Uploaded 2010-11-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
195114	Paper Form (mailed)	Form and Instruction	New
195110	Personal Interview (SSA Field Office)	Other-Intranet Screens	New

ICR Details

OMB Control No: 0960-0784	ICR Reference No: 201011-0960-002
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 11/22/2010
OIRA Conclusion Action: Withdrawn	Conclusion Date: 11/17/2010
	Date Received in OIRA: 11/17/2010
Terms of Clearance: Withdrawn at agency's request.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		6 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Per the Medicare Modernization Act of 2003, selected Medicare insurance recipients pay an income-related monthly adjustment amount (IRMAA). The Internal Revenue Service (IRS) transmits income tax return data to SSA for SSA to determine the amount of IRMAA. SSA will use the new Form SSA–44 to determine if a recipient qualifies for a reduction in IRMMA. If affected Medicare recipients believe SSA should use more recent tax data because a life-changing event occurred that significantly reduces their income, they can report these changes to SSA and ask for a new initial determination of their IRMAA.

Emergency Justfication: The Social Security Administration (SSA) needs to replace the current OMB-approved form, the SSA-44 (OMB No. 0960-0735, Medicare Part B Income-Related Premium - Life-Changing Event) because of statutory changes. SSA seeks approval to replace that form with a new SSA-44 entitled “Medicare Income-Related Premium – Life-Changing Event” which will address those statutory changes.

---

Authorizing Statute(s): US Code: 42 USC 1395r Name of Law: The Social Security Act
   US Code: 42 USC 1395w-104 Name of Law: The Social Security Act
   PL: Pub.L. 111 - 148 3308 Name of Law: The Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3308 Name of Law: The Patient Protection and Affordable Care Act

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 70341	11/17/2010
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Paper Form (mailed)	SSA-44	Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event
Personal Interview (SSA Field Office)

---

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: This new information collection will increase the public reporting burden due to a statutory change.

---

Annual Cost to Federal Government: $8,500,000

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

---

Common Form ICR:  No

---

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: 11/17/2010

---