Redetermination of Eligibility for Help with Medicare Prescription Drug Plan Costs

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form New SSA-1026-OCR-S SSA- 1026-REDE SSA Review of Your Eligibility for Extra Help	Form and Instruction	Modified	Available
Form SSA-1026-SCE SSA-1026-SCE - Reporting a Change That May Affect Your Extra Help	Form and Instruction	Modified	Available
Supporting Statement 0960-0723.doc	Supporting Statement A	Uploaded 2014-09-29	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9780	SSA- 1026-REDE SSA Review of Your Eligibility for Extra Help	Form and Instruction	Modified
212610	SCE Field Office Interview	Other-Interview Screens	New
212609	REDE Field Office Interview	Other-Interview Screens	New
187637	SSA-1026-SCE - Reporting a Change That May Affect Your Extra Help	Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0723	ICR Reference No: 201408-0960-003
Status: Historical Active	Previous ICR Reference No: 201108-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Redetermination of Eligibility for Help with Medicare Prescription Drug Plan Costs
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: 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	01/31/2015
Responses	170,942	0	236,400
Time Burden (Hours)	51,283	0	70,920
Cost Burden (Dollars)	0	0	0

---

Abstract: As required by the Medicare Modernization Act of 2003 (P.L. 108-173), SSA conducts low-income subsidy eligibility redeterminations for Medicare beneficiaries who filed for the subsidy and were determined by SSA to be eligible. SSA conducts subsidy eligibility redeterminations under two circumstances: 1) When an individual completes Form SSA-1026-OCR-SM-SCE to report a subsidy-changing event (marriage, separation from a spouse, separated spouses resume living together, divorce, annulment, or death); and 2) When SSA uses Form SSA-1026-OCR-SM-REDE to conduct an annual review of individuals who became entitled during the prior 12 months, an annual review of a percentage of individuals who are eligible for more than 12 months, and a review of individuals who report a change in income, resources, or household size that may affect the subsidy amount.

---

Authorizing Statute(s): US Code: 42 USC 1395w-101 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: 4

table that charts list of burden

IC Title	Form No.	Form Name
SCE Field Office Interview
SSA- 1026-REDE SSA Review of Your Eligibility for Extra Help	New SSA-1026-OCR-SM-REDE	SSA Review of Your Eligibility for Extra Help
SSA-1026-SCE - Reporting a Change That May Affect Your Extra Help	SSA-1026-SCE	SSA - Reporting a Change That May Affect Your Extra Help
REDE Field Office Interview

---

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	170,942	236,400	0	0	-65,458	0
Annual Time Burden (Hours)	51,283	70,920	0	0	-19,637	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: The number of respondents decreased since the last information collection due to SSA conducting fewer redeterminations.

---

Annual Cost to Federal Government: $61,131

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

---