Continuation of Supplemental Security Income Payments for the Temporarily Institutionalized – Certification of Period and Need to Maintain Home

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-186 Temporary Institutionalization Statement to Maintain Household and Physician Certification	Form	Modified	Available
Form SSA-186 Temporary Institutionalization Statement to Maintain Household and Physician Certification	Form and Instruction	New	Available
Addendum - 0516 (Final).docx	Supplementary Document	Uploaded 2021-09-29	Available
Addendum - 0516 (Final).docx	Supplementary Document	Uploaded 2021-09-29	Repair queued
Supporting Statement - 0516 (Clean Copy).docx	Supporting Statement A	Uploaded 2023-06-13	Available
Supporting Statement - 0516 (Final).docx	Supporting Statement A	Uploaded 2021-09-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9422	Continuation of SSI Benefits for the Temporarily Institutionalized - Certification of Period and Need to Maintain Home - Statement from other Respondents	Form	Modified	Temporary Institutionalization Statement to Maintain Household and Physician Certification
9422	Continuation of SSI Benefits for the Temporarily Institutionalized - Certification of Period and Need to Maintain Home - Statement from other Respondents	Other-SSI Claims System Screens	Modified
260647	Continuation of SSI Benefits for the Temporarily Institutionalized - Certification of Period and Need to Maintain Home - Physician's Certifications	Form and Instruction	New	Temporary Institutionalization Statement to Maintain Household and Physician Certification
260647	Continuation of SSI Benefits for the Temporarily Institutionalized - Certification of Period and Need to Maintain Home - Physician's Certifications	Other-Intranet Screens	New

ICR Details

OMB Control No: 0960-0516	ICR Reference No: 202105-0960-001
Status: Active	Previous ICR Reference No: 201807-0960-011
Agency/Subagency: SSA	Agency Tracking No:
Title: Continuation of Supplemental Security Income Payments for the Temporarily Institutionalized – Certification of Period and Need to Maintain Home
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: 06/15/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/30/2021
Terms of Clearance: The agency made substantial modifications to the supporting statement to provide greater detail regarding the burdens associated with this information collection. No later than one-year after deployment of this new instrument, the agency will offer OMB a briefing on the use of this form and any impacts to increased access to TI benefits and/or reductions in overpayments.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2026	36 Months From Approved	06/30/2023
Responses	53,586	0	60,000
Time Burden (Hours)	21,881	0	5,000
Cost Burden (Dollars)	0	0	0

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Abstract: SSA collects this information to determine if institutionalized SSI recipients will only be in the institution or medical facility for three months maximum, and if they still need SSI payments. To do this, the recipient, the recipient’s representative payee, or if the recipient does not have a representative payee, someone on their behalf typically calls SSA to provide the statement of need, and a signed physician’s certification is sent via mail. In addition, SSA employees upon finding out about a recipient entering an institution can contact the recipient or recipient’s representative payee to obtain the statement of need and a physician's certification. SSA accepts a certification or copy of a certification signed by the recipient’s physician, attesting to the period of confinement. SSA accepts a signed statement or a verbal confirmation from the recipient, or from the representative payee, acting on behalf of the recipient, about the need to maintain a home. In addition, SSA created an official form, the SSA-186, Temporary Institutionalization Statement to Maintain Household and Physician Certification, that collects the signature of the SSI recipient, provides the statement of need, and the physician’s signature providing the physician’s certification with the time period of confinement. The form asks the same questions that are on the SSI Claims System screens. The respondents are medical providers, and SSI recipients or their representative payees.

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Authorizing Statute(s): US Code: 42 USC 1382 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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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:
	86 FR 33007	06/23/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 54007	09/29/2021
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Continuation of SSI Benefits for the Temporarily Institutionalized - Certification of Period and Need to Maintain Home - Physician's Certifications	SSA-186	Temporary Institutionalization Statement to Maintain Household and Physician Certification
Continuation of SSI Benefits for the Temporarily Institutionalized - Certification of Period and Need to Maintain Home - Statement from other Respondents	SSA-186	Temporary Institutionalization Statement to Maintain Household and Physician Certification

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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	53,586	60,000	0	0	-6,414	0
Annual Time Burden (Hours)	21,881	5,000	0	0	16,881	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 collection in 2018, the burden was 5,000 hours. However, we are currently reporting a burden of 13,396 hours. This change stems from a decrease in the number of responses from 60,000 to 53,586, as well as an increase in burden time per response from 5 to 15 minutes. 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 21,881, while the burden cited in #12 of the Supporting Statement is 13,396. This discrepancy is because the ROCIS burden reflects the following components: Teleservice Center waiting time. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

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Annual Cost to Federal Government: $192,721

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.     No

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.     No

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: 09/30/2021

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