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	Modified	Repair queued
Supporting Statement 0960-0773.docx	Supporting Statement A	Uploaded 2011-04-27	Available
Addendum.doc	Supplementary Document	Uploaded 2011-03-23	Available

IC Document Collections

Information collection document groups

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

ICR Details

OMB Control No: 0960-0773	ICR Reference No: 201101-0960-003
Status: Historical Active	Previous ICR Reference No: 200806-0960-001
Agency/Subagency: SSA	Agency Tracking No:
Title: Medicare Modernization Act Outreach Program
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: 08/18/2011
	Date Received in OIRA: 05/05/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2014	36 Months From Approved	08/31/2011
Responses	75,000	0	105,000
Time Burden (Hours)	1,250	0	1,750
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 uses an outreach program. Pharmacies, doctors' offices, and medical clinics 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 includes an insert beneficiaries complete to request form SSA-1020 from SSA. SSA makes automated 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:
	76 FR 8394	02/14/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 23640	04/27/2011
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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

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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	75,000	105,000	0	-30,000	0	0
Annual Time Burden (Hours)	1,250	1,750	0	-500	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: We are removing the automated follow-up telephone call (Medicare Automated Reminder System Message) as a collection instrument. We incorrectly reported a burden for this activity when we last cleared this ICR. This activity is an automated, pre-recorded telephone message played to respondents. There is no public burden associated with this activity.

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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]? 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: 05/05/2011

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