Supporting Statement - 0323

Supporting Statement for Form SSA-8019-U2

Third Party Liability Information Statement

42 CFR 433.136-433.139

OMB No. 0960-0323

1. Justification

1. Introduction/Authoring Laws and Regulations

To reduce Medicaid costs, Medicaid state agencies identify third-party insurers liable for medical care or services for Medicaid recipients. Under 42 CFR 433.136 ‑ 433.139, Medicaid state agencies obtain this information on Medicaid applications and redeterminations as a condition of Medicaid eligibility. Under 42 U.S.C 1383c(a), states may enter into agreements with the Social Security Administration (SSA) to make Medicaid eligibility determinations for aged, blind and disabled beneficiaries in those states. Applications for and redeterminations of Supplemental Security Income (SSI) eligibility in jurisdictions with such agreements are also applications and redeterminations of Medicaid eligibility.

2. Description of Collection

To reduce Medicaid costs, Medicaid state agencies identify third party insurers liable for medical care or services for Medicaid beneficiaries. Applications for and redeterminations of SSI eligibility in jurisdictions with such agreements are applications and redeterminations of Medicaid eligibility. Under these agreements, SSA obtains third party liability information using Form SSA-8019, and provides that information to the Medicaid state agencies. The Medicaid state agencies use the information to bill third party liable for medical care, support, or services for a beneficiary to guarantee that Medicaid remains the payer of last resort. The respondents are SSI claimants and recipients.

3. Use of Information Technology to Collect the Information

SSA usually collects the information on this form through the SSI Claims System. In the SSI Claims System, SSA personnel completes the third party liability information, when necessary, for initial claims and redetermination situations (when there is a change in third party liability coverage or other specific post eligibility changes). SSA electronically transmits the third party liability information to the state Medicaid agency. Although we do not require the state to complete any part of the form, there are situations when SSA will mail a paper SSA-8019 to the state third-party liability agency. These situations include:

• Non-SSI Claims System initial claims that are allowed;

• Non- SSI Claims System redetermination or post-eligibility action with changes in third party liability circumstances; or

• SSI Claims System claims when complete third party liability information was not available at the time SSA adjudicated the claim

In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an Intranet version of Form SSA-8019-U2. Based on our data, we estimate approximately 99% of respondents under this OMB number use the electronic version.

4. 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,

5. Minimizing Burden on Small Respondents

This collection does not significantly affect a substantial number of small businesses or other small entities,

6. Consequences of Not Collecting Information or Collecting it Less Frequently

Congress made the provision of third party liability information a condition of Medicaid eligibility because it saves significant Federal dollars. Since we are required by law to request the information, SSA 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.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on March 21, 2018, at

83 FR 12455, and we received no public comments. The 30-day FRN published on June 8, 2018 at 83 FR 26736. 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.

9. Payment or Gifts to Respondents

SSA does not provide payments or gifts to the respondents.

10. Assurance of Confidentiality

SSA protects and holds confidential the information it is requesting 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.

11. Justification for Sensitive Questions

The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)
SSA-8019-U2 Paper Form	200		5	17
Intranet version (MSSICS)	49,621		5	4,135
Totals	49,821			4,152

The total burden for this ICR is 4,152 hours. We based these figures on current management data. This figure represents burden hours, and we did not calculate a separate cost burden.

13. Annual Cost to the Respondent

This collection does not impose a known cost burden on the respondents.

14. Annual Cost to the Federal Government

The annual cost to the Federal Government is approximately $430,423. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time; and (3) systems development, updating, and maintenance costs.

15. Program Changes or Adjustments to the Information Collection Request

When we last cleared this collection in 2015, the burden was 4,229 hours. However, we are currently reporting a burden of 4,152 hours. This change stems from normal workload variation and a decrease in the number of respondents. There are no changes to the estimated burden per response. Although the number of responses changed, SSA did not take any actions to cause this change.

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.

For the Intranet version of Form SSA-8019-U2, SSA is not requesting an exception to the requirement to display the OMB approval expiration date.

18. Exception 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).

2. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.