Representative Payee Report and
Physician’s/Medical Officer’s statement
1240-0020
January 20018
SUPPORTING STATEMENT
REPRESENTATIVE PAYEE REPORT
REPRESENTATIVE PAYEE REPORT (Short Form)
PHYSICIAN'S/MEDICAL OFFICER'S STATEMENT
1240-0020
Justification.
1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collections. Attach a copy of the appropriate section of each statute and of each regulation mandating or authorizing the collection of information.
CM-623 and CM-623S
Benefits due a black lung beneficiary may be paid to a representative payee on behalf of the beneficiary when the beneficiary is unable to manage his/her benefits due to incapability, incompetence or being a minor. The CM-623 Representative Payee Report, is used to collect expenditure data regarding the disbursement of the beneficiary's benefits by the payee to assure that the beneficiary's needs are being met. The Black Lung Benefits Act, 30 U.S.C. 922, and 20 CFR 725.510, 511, and 513 necessitate this information collection. The CM-623 is used to ensure that benefits paid to the representative payee are used for the beneficiary’s care and well-being.
The CM-623S Representative Payee Report (Short Form) is sent to representative payees who are relatives of and who live with the beneficiary. The CM-623S requires less detailed certification from the representative payee than the CM-623 requires. The CM-623S was developed because relatives of the beneficiary who live with him/her felt that to have to complete the regular form CM-623 was an unwarranted burden, since the regular form requires such detailed verification. To have to complete a form in such detail by someone who is a close family member and who apparently has the beneficiary's best interests in mind seemed unnecessarily burdensome for this category of representative payee. The CM-623S is used when the representative payee is a family member residing with the beneficiary to ensure that benefits paid to the representative payee are used for the beneficiary’s care and well-being.
CM-787
In certain instances, benefits due a black lung beneficiary may be paid to another person on behalf of the beneficiary when the beneficiary is unable to manage his/her benefits due to incapability or incompetence. To determine incapability or incompetence, certain medical information needs to be obtained from a physician. The CM-787 serves this function. It is used in a small percentage of representative payee cases. The Black Lung Benefits Act, 30 U.S.C. 922, and 20 CFR 725.506 necessitate this information collection. The CM-787 is used to help determine if the beneficiary requires assistance in managing his/her benefits because of impairment.
2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.
CM-623 and CM-623S
The CM-623 and CM-623S were originally created and issued manually by claims staff for representative payees to report utilization of annual benefits received on behalf of a beneficiary. A few years ago, the CM-929P (1240-0028 Exp. Date 12/31/2017) was created and is issued automatically for representative payees to certify annually that the benefits they receive on behalf of a beneficiary are used for the beneficiary’s care and well-being. Currently, the representative payee completes the CM-623/CM-623S to provide a final accounting of benefits received on behalf of a beneficiary. Commonly, final utilization is due to the death of the beneficiary or when there is a change in representative payee determination. The claims staff reviews the form and determines if the representative payee used the benefits for the beneficiary’s needs. If no reporting and accounting were required, the DCMWC would have no way of knowing if a representative payee properly used a beneficiary's money to provide the beneficiary's care and well-being. This could result in potential fraud and abuse.
CM-787
If the District Director has reason to believe that a beneficiary may not be able to manage his/her benefits, and if medical information is needed to help determine the beneficiary's incapability, the patient's physician or a medical officer is requested to report the beneficiary's capability to manage benefits to DCMWC on a one time only basis or, as appropriate, if the beneficiary later becomes capable of managing benefits. Without the CM-787, the claims staff would have no uniform way of requesting this type of medical information.
3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.
CM-623, CM-623S, and CM-787
All three forms are currently available on the Internet for downloading, on-screen filling, and printing at: http://www.dol.gov/owcp/dcmwc/regs/compliance/blforms.htm.
The CM-623 and CM-623S contain space for the signature of a witness if the person completing the form is unable to sign his or her name. Two independently-obtained digital signatures by different people would be required to submit such a form on-line and, in order to keep claim information confidential, the Department of Labor’s web site does not permit forwarding or submission of on-line forms to any electronic address other than the Department’s designated electronic mailbox. This would prevent the payee from forwarding the form to the witness after both had received their digital signature verification keys. The CM-787 is similarly fillable. Although there is no space for a witness, the form is pre-filled by the claims staff with the beneficiary’s name, address, and identifying information before it is mailed to the physician for completion and signature. The physician has the option to mail completed forms in the provided return envelope or submit the CM-787 electronically through the COAL Mine Portal at https://eclaimant.dol-esa.gov/bl.
4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.
There is no similar information available.
5. If the collection information impacts small businesses or other small entities, describe any methods used to minimize burden.
CM-623
Small businesses such as nursing homes, long-term care facilities, boarding houses, etc. would be involved. If the beneficiary were a resident in that type of institution and that institution were appointed the representative payee, the institution's administrator would be required to give an accounting of the use of the beneficiary's benefits. The only burden would be the completion of the CM-623 form. Since the information needed for completion should be part of the small business's regular accounting procedure, and is only required on occasion, the burden on small businesses would be minimal.
CM-623S
Since this form will only be completed by a relative living with the beneficiary, there are no small businesses involved.
CM-787
Small businesses such as physicians are involved. The only burden is the completion of a short form. The medical information, for the most part, is already a matter of record and the physician would affirm the facts for DOL/DCMWC records.
There is no significant economic impact on a substantial number of small entities.
6. Describe the consequence of Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.
CM-623 and CM-623S
DCMWC mails the report to the appropriate representative payee when necessary. Since annual reporting is accomplished on OMB 1240-0128, the CM-623 and CM-623S will be used on those occasions when an additional report is needed, such as a change in representative payee or a final accounting following the death of a beneficiary. If final reporting were not done, the potential for fraud and abuse would increase as representative payees would not be held accountable for use of the beneficiaries’ monies.
CM-787
DCMWC mails the request for the physician's statement on a one-time basis. The physician's response is brief for pertinent information. If this information were not obtained, there would not be any other means to determine the beneficiary's capability to manage benefits from a medical view.
7. Explain any special circumstance required in the conduct of this information collection:
There are no special circumstances for this information collection.
8. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8 (d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments.
A Federal Register Notification inviting public comment was published October 13, 2017 (82 FR 47772). No public comments were received.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
Respondents do not receive gifts or payments to furnish the requested information.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulations, or agency policy.
Each completed form is maintained in the beneficiary’s case file. Information collections involving a beneficiary’s record is covered by the Privacy Act System of Records, DOL/OWCP-2, published at 81 Federal Register 25765, 25858 (April 29, 2016), or as updated and republished.
Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary; the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
This collection contains no questions of a sensitive nature.
Provide estimates of the hour burden of the collection of information. The statement should:
Indicate the number of respondents, frequency of response, annual hour burden, and an explanation of how the burden was estimated. Unless directed to do so, agencies should not make special surveys to obtain information on which to base burden estimates. Consultation with a sample of potential respondents is desirable. If the burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated burden and explain the reason for the variance. Generally, estimates should not include burden hours for customary and usual business practices.
CM-623
An annual average of 300 CM-623 forms will be sent to representative payees who are not family members residing with beneficiaries. It takes these representative payees approximately one and 1/2 hours to complete the form and mail it. This results in 450 burden hours. (90 X 300/60 = 450)
CM-623S
An annual average of 325 CM-623S forms will be sent to representative payees who are family members of, and who live with, beneficiaries. It takes these representative payees approximately 10 minutes to complete the form and mail it. This results in 54 burden hours. (325 X 10/60 = 54)
CM-787
An annual average of 700 CM-787 forms are sent to physicians. It takes the physician approximately 15 minutes to complete the form and mail it. This results in 175 burden hours. (700 X 15/ 60 = 175)
Total burden hours for the CM-623, CM-623S, and CM-787 are:
CM-623: 450
CM-623S: 54
CM-787: 175
Total: 679 burden hours
We estimate the annualized cost for the burden hours for 90% of the CM-623 and 100% of CM-623S respondents (individuals and family members) by applying the minimum wage per hour of $7.25 https://www.dol.gov/general/topic/wages/minimumwage.
We estimate the annualized cost to 10% of the CM-623 respondents by applying the hourly wage of $19.34 for bookkeeping and accounting clerks taken from the May 2016 National Occupational Employment and Wage Estimates, published by the Bureau of Labor Statistics at http://www.bls.gov/oes/current/oes433031.htm.
We estimate the annualized cost to the CM-787 respondents by applying the hourly wage of $113.18 for physicians, taken from the May 2016 National Occupational Employment and Wage Estimates, published by the Bureau of Labor Statistics at
http://www.bls.gov/oes/current/oes291069.htm.
CM-623 405 hours x $7.25 = $2,936.25
CM-623 45 hours x $19.34 = $870.03
CM-623S 54 hours x $7.25 = $391.50
CM-787 175 hours x $113.18 = $19,806.50
The total annualized burden cost for respondents is $24,004.28.
Annual Costs to Respondents (capital/start-up & operation and maintenance).
There are no operation and maintenance costs associated with the three forms. Return postage is provided.
14. Provide estimates of annualized cost to the Federal government.
The total annualized Federal cost estimate for the three forms is $13,857.02.
CM-623
The Federal cost estimate of $6,220.50 was determined for an average annual usage of 300 forms as follows:
o mailing 300 x $.52 per form = $156.00
$.49 postage plus $.03 envelope
300 X $.62 per form = $186.00
.49 + .10 + .03 = .62
(postage paid return envelope
+ .10 postal surcharge per envelope)
o processing A GS-12/5-RUS1
($39.19 per hour) spends 30 minutes
processing each form.
300 forms x 1/2 hour = 150 hours
150 hours x $39.19= $5,878.50
CM-623S
The Federal cost estimate of $414.27 was determined for an average annual usage of 54 forms as follows:
o mailing 54 x $.52 per form = $28.08
$.49 postage plus $.03 envelope
54 X $.62 per form = $33.48
.49 + .10 + .03 = .62
(postage paid return envelope + .10 postal surcharge per envelope)
o processing A GS-12/5 ($39.19 per hour) spends 10 minutes processing each form.
54 forms x 1/6 hour = 9 hours
9 hours x $39.19 = $352.71
CM-787
The Federal cost estimate of $7,222.25 was determined for an average annual usage of 700 forms as follows:
o mailing 700 x $.52 per form = $364.00
$.49 postage plus $.03 envelope
o processing A GS-12/5 ($39.19 per hour)spends
15 minutes processing each form.
700 forms x 15 minutes = 175 hours
175 hours x $39.19 = $6,858.25
Federal Cost Summary
CM-623 $6,220.50
CM-623S $414.27
CM-787 $7,222.25
Total Federal Cost $13,857.02
15. Explain the reasons for any program changes or adjustments.
The total decrease in the total burden hours for all three forms is 963 hours. The CM-623 and CM-623S are no longer used as the annual accounting of a beneficiary’s benefits, but rather are just used for the final accounting of a beneficiary’s benefits, due to death or due to a change in representative payee appointment. The number of burden hours for form CM-787 has decreased due to fewer determinations of incapability or incompetence medical opinions needed.
Specific changes to each form:
CM-623
Under Instructions, updated language.
Under Notice, updated language.
Changed heading of “Paperwork/Privacy Act Notice” to “Privacy Act Notice”.
Updated Privacy Act Notice paragraph.
Under Notice, removed “examiner” and replaced with “staff”
On page 1 of Representative Payee Report, removed “Claim Number” and replaced with “DOL’s Case ID Number.
Under Item 10 (page 3), removed “shall” and replaced with “must”.
Above signature block on page 3, updated warning paragraph.
CM-623S
First two paragraphs of Instructions updated.
Updated the Notice paragraph with warning language.
Change “Paperwork/Privacy Act Notice” title to “Privacy Act Notice”.
Updated the Privacy Act Notice paragraph.
Changed “examiner” to “staff” under the Notice.
Removed “Claim Number” to first page of report.
Added “DOL’s Case ID Number” to first page of report.
CM-787
Introduction paragraph was updated.
Reference to “his” was updated to “his/her”.
Sentence added to introduction paragraph: Include additional information under “Remarks”.
Removed “Patient’s Social Security No:”
Added: “DOL’s Case ID Number:”
The warning statement was updated.
Below signature block, “Two Filing Options” were added.
First paragraph under the Instructions was removed.
Second paragraph under the Instructions: added “who” between “older” and “is”. Same paragraph, removed “to how” between “others” and “to”, in the last sentence.
Fourth paragraph under the Instructions: removed “returning” and replaced with “filing”.
Privacy Act Notice updated.
Duplicate Public Burden Statement removed.
Under “Notice”, removed “examiner” and replaced with “staff” in last sentence.
16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection information, completion of report, publication dates, and other actions.
There are no plans to publish this collection of information.
17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
This request does not seek a waiver from the requirement to display the expiration date.
18. Explain each exception to the certification statement identified in ROCIS.
There are no exceptions to the certification statement.
B. Collections of Information Employing Statistical Methods.
Statistical methods are not used in these collections of information.
1 Federal rates are from the OPM GS Salary Tables at https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2017/RUS_h.pdf.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | SUPPORTING STATEMENT |
| Author | Debra Thurston |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |