Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event

Forms and Documents

Document	Type	Status	Availability
Form SSA-44 Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event	Form and Instruction	Modified	Available
Supporting Statement - 0784 (Final).docx	Supporting Statement A	Uploaded 2024-07-24	Available
Supporting Statement - 0784.docx	Supporting Statement A	Uploaded 2020-10-02	Repair queued
Addendum - 0784.docx	Supplementary Document	Uploaded 2020-10-01	Available
Addendum - 0784.docx	Supplementary Document	Uploaded 2020-10-01	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
195114	Paper Form SSA-44 (mailed or fillable PDF)	Form and Instruction	Modified	Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event
195114	Paper Form SSA-44 (mailed or fillable PDF)	Other-0784 Privacy Act Statement (revised)	Modified
195110	Personal Interview (SSA Field Office)	Other-Intranet Screens	Modified

ICR Details

OMB Control No: 0960-0784	ICR Reference No: 202010-0960-002
Status: Active	Previous ICR Reference No: 201811-0960-011
Agency/Subagency: SSA	Agency Tracking No:
Title: Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/25/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/02/2020
Terms of Clearance: The agency made modifications to the Supporting Statement A to provide further discussion of how income tax filing information is used to calculate the premium subsidy reduction. The agency made minor modifications to the SSA-44 to reduce burden and also increased the burden estimates.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2027	36 Months From Approved	07/31/2024
Responses	255,485	0	200,540
Time Burden (Hours)	307,860	0	115,311
Cost Burden (Dollars)	0	0	0

---

Abstract: Per the Medicare Modernization Act of 2003, selected Medicare insurance recipients pay an income-related monthly adjustment amount (IRMAA). The Internal Revenue Service (IRS) transmits income tax return data to SSA for SSA to determine the amount of IRMAA. SSA uses Form SSA-44 to determine if a recipient qualifies for a reduction in IRMMA. If affected Medicare recipients believe SSA should use more recent tax data because a life-changing event occurred that significantly reduces their income, they can report these changes to SSA and ask for a new initial determination of their IRMAA.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 3308 Name of Law: The Patient Protection and Affordable Care Act
   US Code: 42 USC 1395w-104 Name of Law: The Social Security Act
   US Code: 42 USC 1395r Name of Law: The Social Security Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3308 Name of Law: The Patient Protection and Affordable Care Act

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 45723	07/29/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 60509	09/25/2020
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Paper Form SSA-44 (mailed or fillable PDF)	SSA-44	Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event
Personal Interview (SSA Field Office)

---

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	255,485	200,540	0	0	54,945	0
Annual Time Burden (Hours)	307,860	115,311	0	0	192,549	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: When we last cleared this IC in 2017, the burden was 115,311 hours. However, we are currently reporting a burden of 146,904 hours. This change stems an increase in the number of responses from 200,540 to 255,485. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change. These figures represent current Management Information data. * Note: The total burden reflected in ROCIS is 307,860, while the burden cited in #12 of the Supporting Statement is 146,904. This discrepancy is because the ROCIS burden reflects the following components: field office waiting time + a rough estimate of a 30-minute, one-way, drive burden. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

---

Annual Cost to Federal Government: $244,079,109

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]? Yes

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? No

---

Common Form ICR:  No

---

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: 10/02/2020

---