Addendum to the Supporting Statement for the SSA-8510

Addendum to the Supporting Statement for Form SSA-8510

Authorization for the Social Security Administration to Obtain Personal Information

20 CFR 404.704; 404.820 - 404.823; 404.1926; 416.203; and 418.3001

OMB No. 0960-NEW

In Use Without OMB Approval

In April 2015, we became aware that SSA field offices use this form to obtain personal information for general purposes under all SSA programs, and not just for the Medicare subsidy usage we initially obtained OMB approval for under 0960‑0707. Since we are expanding the OMB approval for this form, we are also requesting a new OMB Control Number, as 0960-0707 is specifically associated with Medicare benefits.

Based on our current usage of this form, we are also creating a new electronic version of the application as part of our Modernized Supplemental Security Income Claims System (MSSICS). See Revisions to the Collection Instrument section below.

Revisions to the Collection Instrument

This is a revision to an existing collection under OMB 0960-0707, in which the form is limited to the collection for Medicare part D subsidy information. As mentioned above, the revised OMB package will create a stand-alone SSA-8510 under a new OMB number to collect information regarding all SSA programs.

Below is a summary of changes for SSA-8510. These revisions expand the scope of the form and add an electronic version of the form in the Modernized Supplemental Security Income Claims System (MSSICS).

• Change #1: We are expanding the scope of the SSA-8510 from Medicare part D subsidy information only to request general evidence information to support a benefit application or payment continuation under Titles II and XVI of the Social Security Act.

Justification #1: As mentioned in the section above, we inadvertently used this form for a larger scope than OMB initially approved, but we are correcting the oversight now by expanding the scope. The new scope will cover general evidence requests such as:

• Age requirements (e.g. birth certificate, court documents)

• Insured status (e.g. earnings, employer verification)

• Marriage or divorce information

• Pension Offsets

• Wages verification

• Annuities

• Property information

• Benefit verification from a State agency or third party

• Immigration status (rare instances)

• Income verification from public agencies or private individuals

• Unemployment benefits

• Insurance Policies

• Change #2: We are adding a standalone electronic version of the form to our Modernized Supplemental Security Income Claims System (MSSICS) to support benefit eligibility.

Justification #2: MSSICS mirrors the paper version’s format using an electronic collection method. Guided by the MSSICS collection screens, an SSA representative interviews the applicant and inputs the information directly into SSA’s application database. MSSICS also propagates identity and similar information to other screens in the application. In contrast to the paper application, the in-person or telephone interview MSSICS process offers the advantage of improving the information accuracy in recording responses. Therefore, this electronic version will ensure we receive all necessary data from Supplemental Security Income recipients through a personal interview, and will reduce the necessity for our field office staff to follow up with these respondents.

We expect to implement this new electronic version by the end of FY15.

Revisions to the Total Annual Burden

As we are requesting a new OMB Number to cover the expanded use of this form, as well as the new MSSICS version, we expect this will increase the total annual burden, as shown in #12 of the Supporting Statement:

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Annual Burden (hours)
Paper SSA-8510 for Medicare Subsidy Quality Review	3,500	1	5	292
Paper SSA-8510 for general evidence purposes	19,800	1	5	1650
MSSICS	140,145	1	5	11, 679
Totals	163,445			13,621