Medicare Subsidy Quality Review

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-9314 Notice of Quality Review Acknowledgement Form for those without Phones	Form and Instruction	Modified	Repair queued
Form SSA-9314 SSA-9314	Form and Instruction	Modified	Repair queued
Form SSA-9313 Notice of Quality Review Acknowledgement Form for those with Phones	Form and Instruction	Modified	Repair queued
Form SSA-9313 SSA-9313	Form and Instruction	Modified	Repair queued
Form SSA-9310 Request for Documents	Form and Instruction	Modified	Repair queued
Form SSA-9310 SSA-9310	Form and Instruction	Modified	Repair queued
Form SSA-9308 Request for Release of Information	Form and Instruction	Modified	Repair queued
Form SSA-9308 SSA-9308	Form and Instruction	Modified	Repair queued
Form SSA-9312 Notice of Appointment -Denial- Please Call Reviewer	Form and Instruction	Modified	Repair queued
Form SSA-9312 SSA-9312	Form and Instruction	Modified	Repair queued
Form SSA-9311 Notice of Appointment -Denial- Reviewer Will Call	Form and Instruction	Modified	Repair queued
Form SSA-9311 SSA-9311	Form and Instruction	Modified	Repair queued
Form SSA-9303 Notice of Appointment-Please Call Reviewer	Form and Instruction	Modified	Repair queued
Form SSA-9303 SSA-9303	Form and Instruction	Modified	Repair queued
Form SSA-9302 Notice of Appointment - Reviewer Will Call (Revised)	Form and Instruction	Modified	Repair queued
Form SSA-9302 SSA-9302	Form and Instruction	Modified	Repair queued
Supporting Statement - 0707.docx	Supporting Statement A	Uploaded 2021-01-28	Repair queued
Addendum 0707.docx	Supplementary Document	Uploaded 2021-01-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9763	SSA-9301	Other-Telephone Interview Script	Modified
182005	SSA-9314	Form and Instruction	Modified	Notice of Quality Review Acknowledgement Form for those without Phones
182005	SSA-9314	Form and Instruction	Modified
182004	SSA-9313	Form and Instruction	Modified	Notice of Quality Review Acknowledgement Form for those with Phones
182004	SSA-9313	Form and Instruction	Modified
179416	SSA-9310	Form and Instruction	Modified	Request for Documents
179416	SSA-9310	Form and Instruction	Modified
179414	SSA-9308	Form and Instruction	Modified	Request for Release of Information
179414	SSA-9308	Form and Instruction	Modified
179412	SSA-9312	Form and Instruction	Modified	Notice of Appointment -Denial- Please Call Reviewer
179412	SSA-9312	Form and Instruction	Modified
179411	SSA-9311	Form and Instruction	Modified	Notice of Appointment -Denial- Reviewer Will Call
179411	SSA-9311	Form and Instruction	Modified
179409	SSA-9303	Form and Instruction	Modified	Notice of Appointment-Please Call Reviewer
179409	SSA-9303	Form and Instruction	Modified
179409	SSA-9303	Instruction	Modified
179406	SSA-9302	Form and Instruction	Modified	Notice of Appointment - Reviewer Will Call (Revised)
179406	SSA-9302	Form and Instruction	Modified
179406	SSA-9302	Instruction	Modified

ICR Details

OMB Control No: 0960-0707	ICR Reference No: 202010-0960-008
Status: Historical Active	Previous ICR Reference No: 201706-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Medicare Subsidy Quality Review
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/18/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/28/2021
Terms of Clearance: Prior to renewal, the agency will update the supporting statement question prompt #2 to clarify how the agency adjudicates or further investigates respondents who refuse or fail to respond to this voluntary collection. No later than one year prior to resubmission of this information collection for triannual renewal, the agency will evaluate, and share with OMB the reasoning and results of the evaluation, the capacity to electronically receive and process this form through eSubmit or an alternative electronic submission method.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2026	36 Months From Approved	05/31/2023
Responses	21,350	0	21,350
Time Burden (Hours)	5,631	0	5,631
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. As part of its stewardship duties of the Medicare Part D subsidy program, SSA must conduct periodic quality review checks of the information Medicare beneficiaries report on their subsidy applications (Form SSA-1020). SSA uses the Medicare Quality Review program to conduct these checks.

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Authorizing Statute(s): PL: Pub.L. 110 - 275 100 Name of Law: Medicare Improvements for Patients and Providers Act of 2008
   US Code: 42 USC 1395w-114 Name of Law: Social Security Act
  

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:
	85 FR 76142	11/27/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 7446	01/28/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 9

table that charts list of burden

IC Title	Form No.	Form Name
SSA-9301
SSA-9302	SSA-9302	Notice of Appointment - Reviewer Will Call (Revised)
SSA-9303	SSA-9303	Notice of Appointment-Please Call Reviewer
SSA-9308	SSA-9308	Request for Release of Information
SSA-9310	SSA-9310	Request for Documents
SSA-9311	SSA-9311	Notice of Appointment -Denial- Reviewer Will Call
SSA-9312	SSA-9312	Notice of Appointment -Denial- Please Call Reviewer
SSA-9313	SSA-9313	Notice of Quality Review Acknowledgement Form for those with Phones
SSA-9314	SSA-9314	Notice of Quality Review Acknowledgement Form for those without Phones

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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	21,350	21,350	0	0	0	0
Annual Time Burden (Hours)	5,631	5,631	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: $245,934

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? No

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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: 01/28/2021

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