Third Party Liability Information Statement

ICR 201201-0960-008

OMB: 0960-0323

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2012-04-16
Supplementary Document
2012-07-19
IC Document Collections
ICR Details
0960-0323 201201-0960-008
Historical Active 200812-0960-014
SSA
Third Party Liability Information Statement
Revision of a currently approved collection   No
Regular
Approved with change 10/02/2012
Retrieve Notice of Action (NOA) 05/02/2012
  Inventory as of this Action Requested Previously Approved
10/31/2015 36 Months From Approved 10/31/2012
67,034 0 62,833
5,586 0 5,236
0 0 0

Medicaid state agencies must identify third party insurers liable for medical care or services for Medicaid beneficiaries; this reduces Medicaid costs. Regulations at 42 CFR 433.136–433.139 require Medicaid state agencies to obtain this information on Medicaid applications and redeterminations as a condition of Medicaid eligibility. States may enter into agreements with the Commissioner of Social Security to make Medicaid eligibility determinations for aged, blind, and disabled beneficiaries in those states. Applications for and redeterminations of Supplemental Security Income (SSI) eligibility in jurisdictions with such agreements are applications and redeterminations of Medicaid eligibility. Under these agreements, SSA obtains third party liability information using Form SSA- 8019 and provides that information to the Medicaid state agencies. The Medicaid state agencies use the information to bill third parties liable for medical care, support, or services for a beneficiary to guarantee that Medicaid remains the payer of last resort. The respondents are SSI claimants and recipients.

US Code: 42 USC 1396a Name of Law: Social Security Act
   US Code: 42 USC 1383c Name of Law: Social Security Act
  
None

Not associated with rulemaking

  77 FR 4854 01/31/2012
77 FR 21616 04/10/2012
No

2
IC Title Form No. Form Name
Third Party Liability Information Statement
Third Party Liability Information Statement SSA-8019-U2 Third Party Liability Information Statement

  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 67,034 62,833 0 0 4,201 0
Annual Time Burden (Hours) 5,586 5,236 0 0 350 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
When we last cleared this information collection in 2008, the burden was 5,236 hours. The change in hours reflects normal workload variations and an increase in the number of respondents.

$531,694
No
No
No
No
No
Uncollected
Faye Lipsky 410 965-8783 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
05/02/2012


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