Medicare Subsidy Quality Review

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-9314 SSA-9314	Form and Instruction	Modified	Available
Form SSA-9313 SSA-9313	Form and Instruction	Modified	Available
Form SSA-8510 SSA-8510	Form and Instruction	Unchanged	Available
Form SSA-9310 SSA-9310	Form and Instruction	Modified	Available
Form SSA-9308 SSA-9308	Form and Instruction	Modified	Available
Form SSA-9312 SSA-9312	Form and Instruction	Modified	Available
Form SSA-9311 SSA-9311	Form and Instruction	Modified	Available
Form SSA-9303 SSA-9303	Form and Instruction	Modified	Available
Form SSA-9302 SSA-9302	Form and Instruction	Modified	Available
Supporting Statement 0960-0707.docx	Supporting Statement A	Uploaded 2014-09-29	Available
Addendum to Supporting Statement 0960-0707.docx	Supplementary Document	Uploaded 2014-08-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9763	SSA-9301	Other-Telephone Interview Script	Modified
182005	SSA-9314	Form and Instruction	Modified
182004	SSA-9313	Form and Instruction	Modified
179417	SSA-8510	Form and Instruction	Unchanged
179416	SSA-9310	Form and Instruction	Modified
179414	SSA-9308	Form and Instruction	Modified
179412	SSA-9312	Form and Instruction	Modified
179411	SSA-9311	Form and Instruction	Modified
179409	SSA-9303	Form and Instruction	Modified
179406	SSA-9302	Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0707	ICR Reference No: 201407-0960-004
Status: Historical Active	Previous ICR Reference No: 201110-0960-005
Agency/Subagency: SSA	Agency Tracking No:
Title: Medicare Subsidy Quality Review
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: 11/07/2014
	Date Received in OIRA: 10/06/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2017	36 Months From Approved	02/28/2015
Responses	24,850	0	24,850
Time Burden (Hours)	5,923	0	5,923
Cost Burden (Dollars)	0	0	0

---

Abstract: The Medicare Modernization Act of 2003 mandated the creation of the Medicare Part D prescription drug coverage program and provided for certain subsidies for eligible Medicare beneficiaries to help pay for the costs of prescription drugs. As part of its stewardship duties of the Medicare Part D subsidy program, SSA must conduct periodic quality review checks of the information Medicare beneficiaries report on their subsidy applications (Form SSA-1020). SSA uses the Medicare Quality Review program to conduct these checks.

---

Authorizing Statute(s): US Code: 42 USC 1395w-114 Name of Law: Social Security Act
   PL: Pub.L. 110 - 275 100 Name of Law: Medicare Improvements for Patients and Providers Act of 2008
  

Citations for New Statutory Requirements: PL: Pub.L. 110 - 275 100 Name of Law: Medicare Improvements for Patients and Providers Act of 2008

---

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:
	79 FR 42863	07/23/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 58022	09/26/2014
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
SSA-8510	SSA-8510	Authorization for the Social Security Administration to Obtain Personal Information
SSA-9301
SSA-9308	SSA-9308	Request for Release of Information
SSA-9311	SSA-9311	Notice of Appointment -Denial- Reviewer Will Call
SSA-9302	SSA-9302	Notice of Appointment - Reviewer Will Call (Revised)
SSA-9303	SSA-9303	Notice of Appointment-Please Call Reviewer
SSA-9312	SSA-9312	Notice of Appointment -Denial- Please Call Reviewer
SSA-9310	SSA-9310	Request for Documents
SSA-9313	SSA-9313	Notice of Quality Review Acknowledgement Form for those with Phones
SSA-9314	SSA-9314	Notice of Quality Review Acknowledgement Form for those without Phones

---

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	24,850	24,850	0	0	0	0
Annual Time Burden (Hours)	5,923	5,923	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: $154,150

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: 10/06/2014

---