Appeal of Determination for Help with Medicare Prescription Drug Plan Costs

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-1021 Appeal of Determination for Help with Medicare Prescription Drug Plan Costs	Form	Modified	Repair queued
Addendum - 0695 (Final).docx	Supplementary Document	Uploaded 2023-12-29	Repair queued
Supporting Statement - 0695 (Final).docx	Supporting Statement A	Uploaded 2023-12-29	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
9749	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version	Form	Modified	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs
9749	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version	Instruction	Modified
227171	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - MAPS Intranet Version	Other-Intranet Screens	Modified

ICR Details

OMB Control No: 0960-0695	ICR Reference No: 202312-0960-004
Status: Active	Previous ICR Reference No: 202008-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Appeal of Determination for Help with Medicare Prescription Drug Plan Costs
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: 11/19/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/29/2023
Terms of Clearance: In accordance with 5 CFR 1320, this information collection is approved.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2027	36 Months From Approved	11/30/2024
Responses	7,150	0	12,563
Time Burden (Hours)	5,029	0	2,094
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses Form SSA-1021, Appeal of Determination for Help With Medicare Prescription Drug Plan Costs, to obtain information from individuals who appeal SSA’s decisions regarding eligibility or continuing eligibility for a Medicare Part D subsidy. The respondents are Medicare beneficiaries, or proper applicants acting on behalf of a Medicare beneficiary, who do not agree with the outcome of an SSA subsidy eligibility determination, and are filing an appeal.

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Authorizing Statute(s): US Code: 42 USC 1395w-101 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:
	88 FR 71068	10/13/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 90223	12/29/2023
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
Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - MAPS Intranet Version
Appeal of Determination for Help with Medicare Prescription Drug Plan Costs - Paper Version	SSA-1021	Appeal of Determination for Help with Medicare Prescription Drug Plan Costs

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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	7,150	12,563	0	0	-5,413	0
Annual Time Burden (Hours)	5,029	2,094	0	0	2,935	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 the IC in 2021, the burden was 2,094 hours. We are now reporting a burden of 1,192 hours. This change stems from a decrease in the number of respondents from 12,563 to 7,150. 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 5,029, while the burden cited in #12 of the Supporting Statement is 1,192. 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 + learning costs. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.

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Annual Cost to Federal Government: $1,693,268

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: 12/29/2023

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