Application for Help with Medicare Prescription Drug Plan Costs

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-1020 Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)	Form and Instruction	Unchanged	Available
Form i1020 Internet Application for Help with Medicare Prescription Drug Plan Costs	Form and Instruction	Unchanged	Available
Justification for Non-Substantive Changes - 0696.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2019-02-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
38067	Application for Help with Medicare Prescription Drug Plan Costs (Paper Form)	Form and Instruction	Unchanged
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	Unchanged

ICR Details

OMB Control No: 0960-0696	ICR Reference No: 201902-0960-001
Status: Active	Previous ICR Reference No: 201710-0960-008
Agency/Subagency: SSA	Agency Tracking No:
Title: Application for Help with Medicare Prescription Drug Plan Costs
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/25/2019
	Date Received in OIRA: 02/01/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2021	06/30/2021	06/30/2021
Responses	986,551	0	986,551
Time Burden (Hours)	464,389	0	464,389
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. The respondents are Medicare beneficiaries or applicants applying for Part D low income subsidy. We are doing a non-substantive change request to replace Medicare Claim Number with Medicare Beneficiary Identifier.

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

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:
	82 FR 55707	11/22/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 4722	02/01/2018
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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

table that charts list 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	986,551	986,551	0	0	0	0
Annual Time Burden (Hours)	464,389	464,389	0	0	0	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:

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Annual Cost to Federal Government: $2,163,411

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: 02/01/2019

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