A. Justification
Introduction/Authoring Laws and Regulations
Public law 108-173, also known as the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), amended Title XVIII of the Social Security Act (Act) to establish a subsidy program to help certain individuals with limited income and resources pay for Medicare Part D prescription drug coverage. We commonly refer to this subsidy program as Extra Help. Some individuals may automatically become eligible for Extra Help if they have Medicare and Supplemental Security Income payments; full Medicaid coverage; or a Medicare Savings Program as a Qualified Medicare Beneficiaries (QMB); Specified Low‑Income Medicare Beneficiaries (SLMB); or are Qualifying Individuals (QI). An individual, or a proper applicant acting on the behalf of an individual, may have to file a valid application to become eligible for the Medicare Part D subsidy.
The Social Security Administration reviews Medicare Part D subsidy applications and makes eligibility determinations. We described Extra Help eligibility criteria in section 1860D-14 of the Act. Section 1860D-14(a)(3)(B)(iv)(II) of the Act requires the Commissioner of the Social Security Administration (SSA) to establish a mechanism for individuals to appeal subsidy eligibility determinations using procedures described in Section 1631(c)(1)(A).
Description of Collection
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.
Use of Information Technology to Collect the Information
SSA uses several modalities, including paper, PDF, and an Intranet application to collect the information on Form SSA-1021. A fillable PDF version of Form SSA‑1021, which respondents can fill out, print, and mail to SSA, is available on SSA’s Internet website. In addition, SSA employees input the information into the Intranet Medicare Application Processing System (MAPS) through an interview process with the respondents. We estimate approximately 77 percent of the appeals are filed using the MAPS electronic system.
Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it precludes duplication. SSA does not use another collection instrument to obtain similar data.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Form SSA-1021, the public would not have a structured way to appeal a subsidy determination in writing. This would violate section 1860D-14 (a)(3)(B)(iv) of the Act. Because we only collect the information once, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.
7. Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on February 21, 2017, at
82 FR 11293, and we received no public comments. The 30-day FRN published on May 23, 2017, at 81 FR 23695. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the revision of this form.
Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
Assurances of Confidentiality
SSA protects and holds confidential the information it collects in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
The total burden for this ICR is 2,387 hours. This chart below represents the estimated total burden hours, and we did not calculate a separate cost burden.
Modality of Completion |
Number of Respondents |
Frequency of Response |
Average Burden Per Response (minutes) |
Estimated Total Burden (hours) |
SSA-1021 (Paper version) |
3,283 |
1 |
10 |
547 |
SSA-1021 (Intranet version - MAPS) |
11,037 |
1 |
10 |
1840 |
Totals |
14,320 |
|
|
2,387 |
13. Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden on the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government for this IC is approximately $53,937. This estimate is a projection of costs for collecting and processing Form SSA‑1021.
15. Program Changes or Adjustments to the Information Collection Request
The reduction in burden hours stems from a decrease in the number of respondents over the past three years.
16. Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
17. Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).
B. Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |