The agency made minor modifications to the Supporting Statement to clarify the operation of the information collection. The agency also removed a wet signature requirement on the form consistent with Sec. 4 (k)(iii) and (iv) of E.O. 14058.
Inventory as of this Action
Requested
Previously Approved
08/31/2027
36 Months From Approved
08/31/2024
35,457
0
49,821
15,886
0
4,152
0
0
0
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 parties 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.
When we last cleared this IC in 2018, the burden was 4,152 hours. However, we are currently reporting a burden of 3,546 hours. This change stems from a decrease in the number of responses from 49,621 to 35,457. In addition, we increased the completion time per response from 5 to 6 minutes, as we reassessed our burden estimate and found that current MI data supports an increase by one minute. These figures represent current Management Information data.
* Note: The total burden reflected in ROCIS is 15,886, while the burden cited in #12 of the Supporting Statement is 3,546. This discrepancy is because the ROCIS burden reflects field office waiting time in addition to the overall burden per response. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.
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:
(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;
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.
Form SSA-8019 Third Party Liability Information Statement
Addendum - 0960-0323 (final).docx
Third Party Liability Information Statement - SSI Claims System