Application for Help with Medicare Prescription Drug Plan Costs

Forms and Documents

Document Name	Status
Form SSA-1020 Application for Help with Medicare Prescription Drug Plan Costs (Paper Form) Form and Instruction	Modified
Form i1020 Internet Application for Help with Medicare Prescription Drug Plan Costs Form and Instruction	Modified
Supporting Statement 0960-0696.doc Supporting Statement A	2014-12-16
Addendum to the Supporting Statement 0960-0696.docx Supplementary Document	2014-10-07

IC Document Collections

IC ID	Document Title	Status
38067	Application for Help with Medicare Prescription Drug Plan Costs (Paper Form) Form and Instruction	Modified
187636	Application for Extra Help With Medicare Prescription Drug Plan Costs (field office interview) Other-Screens for SSA field office interview	Modified
182917	Internet Application for Help with Medicare Prescription Drug Plan Costs Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0696	ICR Reference No: 201409-0960-010
Status: Historical Active	Previous ICR Reference No: 201109-0960-013
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Help with Medicare Prescription Drug Plan Costs
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: 03/18/2015
	Date Received in OIRA: 12/17/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2018	36 Months From Approved	03/31/2015
Responses	1,054,985	0	1,412,040
Time Burden (Hours)	503,974	0	671,921
Cost Burden (Dollars)	0	0	0

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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. SSA uses Form SSA-1020 (and the i1020, its electronic counterpart), the Application for Extra Help with Medicare Prescription Drug Plan Costs, to collect information to make Part D subsidy eligibility determinations.

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Authorizing Statute(s): PL: Pub.L. 110 - 275 100 Name of Law: Medicare Improvements for Patients and Providers Act of 2008
   US Code: 42 USC 1395w-101 Name of Law: Social Security Act
  

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

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 57650	09/25/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 74154	12/15/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Application for Extra Help With Medicare Prescription Drug Plan Costs (field office interview)
Internet Application for Help with Medicare Prescription Drug Plan Costs	i1020	Internet Application for Extra Help with Medicare Prescription Drug Plan Costs
Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)	SSA-1020	Application for Help with Medicare Prescription Drug Plan Costs

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ICR Summary 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	1,054,985	1,412,040	0	0	-357,055	0
Annual Time Burden (Hours)	503,974	671,921	0	0	-167,947	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: We are currently reporting a burden of 503,974 hours. This change stems from a decrease in the number of Medicare beneficiaries applying for Extra Help.

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Annual Cost to Federal Government: $4,787,108

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

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Common Form ICR:  No

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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: 12/17/2014

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