State Supplementation Provisions: Agreements; Payments

ICR 202104-0960-015

OMB: 0960-0240

Federal Form Document

Forms and Documents
Supporting Statement A
IC Document Collections
9161 Modified
45281 Modified
ICR Details
0960-0240 202104-0960-015
Received in OIRA 201805-0960-009
State Supplementation Provisions: Agreements; Payments
Revision of a currently approved collection   No
Regular 11/24/2021
  Requested Previously Approved
36 Months From Approved 12/31/2021
33 54
33 54
0 0

SSA collects the pass-along increase information from each state agency that: (1) administers a state supplementary program; and (2) has agreed to comply with the provisions of the Act. The information we request allows SSA to determine each state's compliance or noncompliance with the pass-along requirements of the Act. Federal participation in the state's Medicaid program, under Title XIX of the Act, is dependent upon SSA’s determination of a state's compliance. States report supplementary payment information annually (for states complying by the maintenance of payment levels method). SSA may ask them to report up to four times per year (for states complying by the total-expenditures method). This collection asks respondents (i.e., states) to confirm their compliance with the pass along requirements, and to provide any changes to their optional supplementary payment rates. The respondents are state agencies administering supplementary income payment programs.

US Code: 42 USC 1382g Name of Law: Social Security Act

Not associated with rulemaking

  86 FR 47190 08/23/2021
86 FR 64585 11/18/2021

IC Title Form No. Form Name
Maintenance of Payment Levels
Total Expenditures

  Total Request 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 33 54 0 0 -21 0
Annual Time Burden (Hours) 33 54 0 0 -21 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
When we last cleared this IC in 2018, the burden was 54 hours. However, we are currently reporting a burden of 33 hours. This change stems from a decrease in the number of responses from 54 to 33. 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.

Faye Lipsky 410 965-8783 [email protected]


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.

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