Supporting Statement SSA-4640 (0960-0729)

Supporting Statement for Form SSA-4640

Authorization for the Social Security Administration to

Obtain Account Records from a Financial Institution and

Request for Records (Medicare)

20 CFR 418.3420

OMB No. 0960-0729

A. Justification

1. Introduction/Authoring Laws and Regulations - The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) established the Medicare Part D program for voluntary prescription drug coverage of premium, deductible, and co-payment costs for individuals with limited income and resources. The MMA mandates that the Government provide subsidies for those individuals who qualify for the program, and who meet eligibility criteria for help with premium, deductible, and/or co-payment costs.

2. Description of Collection - To determine if subsidy applicants or recipients qualify or continue to qualify for the subsidy, the Social Security Administration (SSA) conducts quality reviews of selected applications under the Medicare Quality Review System (OMB No. 0960-0707). As part of the quality review, SSA verifies applicants’ reported financial accounts as discussed in section 20 CFR 418.3420 of the Code of Federal Regulations. To complete this verification, SSA needs to obtain authorization from applicants to contact their financial institutions (FI) to verify the reported account balances. SSA uses Form SSA-4640 to 1) obtain the individual’s consent to verify balances of FI accounts, and 2) to obtain verification of such balances from the FI.

3. Use of Information Technology to Collect the Information - Due to the nature of the form, which requires written signatures/authorizations from two parties (the claimant and the FI) on the same form, SSA does not plan to implement an electronic version of this form.

4. Why We Cannot Use Duplicate Information - The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. Although SSA uses a similar form (SSA-4641, Authorization for The Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records, OMB No. 0960-0293) to obtain FI data for the Supplemental Security Income (SSI) program, that form is specific to the needs of the SSI program. We request more detailed information than is needed for the low-income Medicare subsidy (e.g., monthly account balances). Further, we automatically deem eligible-SSI individuals the low-income subsidy, so there is no danger of the same beneficiary having to complete both forms.

5. Minimizing Burden on Small Respondents - This collection has a minimum impact on small businesses or other small entities.

6. Consequence of Not Collecting Information or Collecting it Less Frequently - If SSA did not collect the information, we would be unable to verify an individual’s eligibility or continued eligibility under the Medicare Quality Review System. Because we only collect the information as needed, we cannot collect it less frequently.

There are no technical or legal obstacles that prevent burden reduction.

7. Special Circumstances - There are no special circumstances that would cause SSA to collect this information in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public - SSA published the 60-day Federal Register Notice on May 11, 2012 at 77 FR 27829, and we received no public comments. We published the 30-day Federal Register Notice on August 10, 2012 at 77 FR 47908. There have been no outside consultations with members of the public.

9. Payment or Gifts to Respondents - SSA provides no payment or gifts to the respondents.

10. Assurances of Confidentiality - SSA protects and holds confidential the information from this form in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.

11. Justification for Sensitive Questions - The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden - Below is the annual reporting burden for this form. The total burden represents burden hours, and we did not calculate a separate cost burden.

Type of Respondent	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimate Total Annual Burden (hours)
Medicare Part D Subsidy Applicants	5,000	1	1	83
Financial Institutions	5,000	1	4	333
Total	10,000			416

13. Annual Cost to the Respondents (Other) - There is no known cost burden to the respondents.

14. Annual Cost to Federal Government - The annual cost to the Federal Government for conducting this collection is approximately $2,200. This estimate is a projection of the costs for printing and distributing the collection instrument, and for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request - There is no change in the public reporting burden.

16. Plans for Publication Information Collection Results - SSA will not publish the results of the information collection.

17. Displaying the OMB Approval Expiration Date - OMB exempted SSA from publishing the expiration date for OMB approval on its forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB clearance. SSA does not periodically revise and reprint its public-use forms, (e.g., on an annual basis). OMB granted this exemption so that SSA would not have to stop using otherwise useable editions of forms with outdated expiration dates thus avoiding Government waste.

18. Exceptions to Certification Statement - SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b) (3).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.