Continuation of SSI Benefits for the Temporarily Institutionalized – Certification of Period and Need to Maintain Home

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Supporting Statement 0960-0516.doc	Supporting Statement A	Uploaded 2012-11-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9422	Continuation of SSI Benefits for the Temporarily Institutionalized – Certification of Period and Need to Maintain Home	Other-MISSICS Screen Used for this Collection	Modified

ICR Details

OMB Control No: 0960-0516	ICR Reference No: 201208-0960-007
Status: Historical Active	Previous ICR Reference No: 200911-0960-009
Agency/Subagency: SSA	Agency Tracking No:
Title: Continuation of SSI Benefits for the Temporarily Institutionalized – Certification of Period and Need to Maintain Home
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/30/2013
	Date Received in OIRA: 12/03/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2016	36 Months From Approved	03/31/2013
Responses	60,000	0	60,000
Time Burden (Hours)	5,000	0	5,000
Cost Burden (Dollars)	0	0	0

---

Abstract: When Supplemental Security Income (SSI) recipients 1) enter a public institution or 2) enter a private medical treatment facility with Medicaid paying more than 50 percent of expenses, their SSI payments are reduced to a nominal sum. However, if this institutionalization is temporary (defined as a maximum of 3 months), SSA may waive the reduction of SSI payments. Before SSA can waive the SSI payment reduction, SSA must receive the following documentation: 1) a physician's certification that the SSI recipient will only be institutionalized for a maximum of 3 months; and 2) certification from the SSI recipient, recipient's family or a friend confirming that SSI benefits are needed to maintain the living arrangements to which the recipient will return post-institutionalization. The respondents are doctors of SSI recipients, the recipients, or their family/friends.

---

Authorizing Statute(s): US Code: 42 USC 1382 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

---

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:
	77 FR 57178	09/17/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 71204	11/29/2012
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Continuation of SSI Benefits for the Temporarily Institutionalized – Certification of Period and Need to Maintain Home

---

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	60,000	60,000	0	0	0	0
Annual Time Burden (Hours)	5,000	5,000	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:

---

Annual Cost to Federal Government: $200,000

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: 12/03/2012

---