Appeal of Determination for Help with Medicare Prescription Drug Plan Costs

Forms and Documents

Document Name	Status
Supporting Statement - 0695.docx Supporting Statement A	2017-06-13
Addendum - 0695.docx Supplementary Document	2017-06-13

IC Document Collections

IC ID	Document Title	Status
9749	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version Instruction	Modified
227171	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - MAPS Intranet Version Other-Intranet Screens	New

ICR Details

OMB Control No: 0960-0695	ICR Reference No: 201703-0960-013
Status: Historical Active	Previous ICR Reference No: 201312-0960-002
Agency/Subagency: SSA	Agency Tracking No:
Title: Appeal of Determination 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: 10/27/2017
	Date Received in OIRA: 06/13/2017
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved for three years.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2020	36 Months From Approved	10/31/2017
Responses	14,320	0	16,338
Time Burden (Hours)	2,387	0	2,723
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses Form SSA-1021, Appeal of Determination for Help With Medicare Prescription Drug Plan Costs, to obtain information from individuals who appeal SSA’s decisions regarding eligibility or continuing eligibility for a Medicare Part D subsidy. The respondents are Medicare beneficiaries, or proper applicants acting on behalf of a Medicare beneficiary, who do not agree with the outcome of an SSA subsidy eligibility determination, and are filing an appeal.

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Authorizing Statute(s): US Code: 42 USC 1395w-101 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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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:
	82 FR 11293	02/21/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 23695	05/23/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version	SSA-1021	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs
Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - MAPS Intranet Version

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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	14,320	16,338	0	0	-2,018	0
Annual Time Burden (Hours)	2,387	2,723	0	0	-336	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 reduction in burden hours stems from a decrease in the number of respondents over the past three years.

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Annual Cost to Federal Government: $53,937

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 06/13/2017

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