2012-1947. Agency Information Collection Activities: Proposed Request and Comment Request

The Social Security Administration (SSA) publishes a list of information collection packages requiring clearance by the Office of Management and Budget (OMB) in compliance with Public Law 104-13, the Paperwork Reduction Act (PRA) of 1995, effective October 1, 1995. This notice includes revisions and extensions of OMB-approved information collections, and a new information collection.

SSA is soliciting comments on the accuracy of the agency's burden estimate; the need for the information; its practical utility; ways to enhance its quality, utility, and clarity; and ways to minimize burden on respondents, including the use of automated collection techniques or other forms of information technology. Mail, email, or fax your comments and recommendations on the information collection(s) to the OMB Desk Officer and SSA Reports Clearance Officer at the following addresses or fax numbers.

(OMB)

Office of Management and Budget, Attn: Desk Officer for SSA. Fax: [phone]. Email address: [e-mail].

(SSA)

Social Security Administration, DCRDP, Attn: Reports Clearance Officer, 107 Altmeyer Building, 6401 Security Blvd., Baltimore, MD 21235. Fax: [phone]. Email address: [e-mail].

I. The information collections below are pending at SSA. SSA will submit them to OMB within 60 days from the date of this notice. To be sure we consider your comments, we must receive them no later than April 2, 2012. Individuals can obtain copies of the collection instruments by calling the SSA Reports Clearance Officer at [phone] or by writing to the above email address.

1. Electronic Health Records Partnering Program Evaluation Form—24 CFR 495.300-495.370—0960-New. The Health Information Technology for Economic and Clinical Health (HITECH) Act promotes the adoption and meaningful use of health information technology (IT), particularly in the context of working with government agencies. Similarly, Section 3004 of the Public Health Service Act requires health care providers or health insurance issuers with government contracts to implement, acquire, or upgrade their health IT systems and products to meet adopted standards and implementation specifications. To support expansion of SSA's health IT initiative as defined under HITECH, SSA developed Form SSA-680, the Partnering Program Evaluation Form. The SSA-680 allows healthcare providers to provide the information SSA needs to determine their ability to exchange health information with us electronically. We intend to evaluate potential partners (i.e., healthcare providers and organizations) on (1) the accessibility of the health information they possess and (2) the content value of their electronic health records' systems for our disability adjudication processes. SSA reviews the completeness of organizations' SSA-680 responses as one part of our careful analysis of their readiness to enter into a health IT partnership with us. The respondents are healthcare providers and organizations exchanging information with the agency.

Type of Request: This is a new information collection request.

Collection instrument	Number of responses	Frequency of response	Average burden per response (hours)	Estimated total annual burden (hours)
SSA-680	30	1	5	150

2. Third Party Liability Information Statement—42 CFR 433.136-433.139—0960-0323. To reduce Medicaid costs, Medicaid state agencies must identify third party insurers liable for medical care or services for Medicaid beneficiaries. Regulations at 42 CFR 433.136-433.139 require Medicaid state agencies to obtain this information on Medicaid applications and redeterminations as a condition of Medicaid eligibility. States may enter into agreements with the Commissioner of Social Security to make Medicaid eligibility determinations for aged, blind, and disabled beneficiaries in those states. Applications for and redeterminations of Supplemental Security Income (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.

Type of Request: Extension of an OMB-approved information collection.

Collection instrument	Number of responses	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-8012 Paper form	130	1	5	11
SSA Intranet Modernized SSI Claims System (MSSICS)	66,904	1	5	5,575
Totals	67,034			5,586

3. Prohibition of Payment of SSI Benefits to Fugitive Felons and Parole/Probation Violators—20 CFR 416.708(o)—0960-0617. Section 1611(e)(4) of the Social Security Act (Act) precludes eligibility for SSI payments for certain fugitives and probation/parole violators. Regulations at 20 CFR 416.708(o) require individuals applying for or receiving SSI benefits to report to SSA that (1) they are fleeing to avoid prosecution for a crime; (2) they are fleeing to avoid custody or confinement after conviction of a crime; or (3) they are violating a condition of probation or parole. SSA will use the information we receive to deny eligibility, or suspend recipients SSI payments. The respondents are SSI applicants and recipients, or representative payees of SSI applicants and recipients, who are reporting their status as a fugitive felon or probation/parole violator.

Type of Request: Extension of an OMB-approved information collection.

Collection instrument	Number of responses	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
MSSICS	1,000	1	1	17

II. SSA submitted the information collections below to OMB for clearance. Your comments regarding the information collections would be most useful if OMB and SSA receive them within 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than March 1, 2012. Individuals can obtain copies of the OMB clearance packages by calling the SSA Reports Clearance Officer at [phone] or by writing to the above email address.

1. Statement of Marital Relationship (By one of the parties)—20 CFR 404.726—0960-0038. SSA must obtain a signed statement from a spousal applicant if the applicant claims a common-law marriage to the insured in a state in which such marriages are recognized, and no formal marriage documentation exists. SSA uses information we collect on Form SSA-754-F4 to determine if an individual applying for spousal benefits meets the criteria of common-law marriage under state law. The respondents are applicants for spouse's Social Security benefits or SSI payments.

This is a correction notice. SSA published this information collection as an extension on November 16, 2011 at 76 FR 71105. Since we are revising the Privacy Act Statement, this is actually a revision of an OMB-approved information collection.

Type of Request: Revision of an OMB-approved information collection.

Collection instrument	Number of responses	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-754-F4	30,000	1	30	15,000

2. Medicaid Use Report—20 CFR 416.268—0960-0267. Section 20 CFR 416.268 of the Code of Federal Regulations requires SSA to determine eligibility for (1) special SSI cash payments and (2) special SSI eligibility status for a person who works despite a disabling condition. It also explains how, in order to qualify for special SSI eligibility status, an individual must establish that termination of eligibility for benefits under title XIX of the Act would seriously inhibit the ability to continue employment. SSA uses the information required by this regulation to determine if an individual is entitled to special title XVI SSI payments and, consequently, to Medicaid. The respondents are SSI recipients for whom SSA has stopped payments based on earnings.

Type of Request: Extension of an OMB-approved information collection.

Regulation section	Number of responses	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
20 CFR 416.268	60,000	1	3	3,000

3. Supplemental Security Income (SSI) Claim Information Notice—20 CFR 416.210—0960-0324. Section 1611(e)(2) of the Act requires individuals to file for and obtain all payments (annuities, pensions, disability benefits, veteran's compensation, etc.) for which they are eligible before qualifying for SSI payments. Individuals do not qualify for SSI if they do not first apply for all other benefits. SSA uses the information on Form SSA-L8050-U3 to verify and establish a claimant's or recipient's eligibility under the SSI program. Respondents are SSI applicants or recipients who may be eligible for other payments from public or private programs.

Type of Request: Revision of an OMB-approved information collection.

Collection instrument	Number of responses	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-L-8050-U3	7,500	1	10	1,250

4. Filing Claims Under the Federal Tort Claims Act—20 CFR 429.101-429.110—0960-0667. The Federal Tort Claims Act is the legal mechanism for compensating persons injured by negligent or wrongful acts that occur during the performance of official duties by Federal employees. In accordance with the law, SSA accepts monetary claims filed under the Federal Tort Claims Act for damages against the United States, loss of property, personal injury, or death resulting from an SSA employee's wrongful act or omission. The regulation sections this information collection comprises require claimants to provide information SSA can use to investigate and determine whether to make an award, compromise, or settlement under the Federal Tort Claims Act. The respondents are individuals or entities making a claim under the Federal Tort Claims Act.

Type of Request: Extension of an OMB-approved information collection.

Regulation section	Number of responses	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
20 CFR 429.102; 20 CFR 492.103 1	—	—	—	1
20 CFR 429.104(a)	31	1	5	3
20 CFR 429.104(b)	25	1	5	2
20 CFR 429.104(c)	2	1	5	.17
20 CFR 429.106(b)	10	1	10	2
Totals	68			8
1 The 1 hour represents a placeholder burden. We are not reporting a burden for this collection because respondents complete OMB-approved Form SF-95 (OMB Control #1105-0008).

Dated: January 25, 2012.

Faye Lipsky,

Reports Clearance Officer, Office of Regulations and Reports Clearance, Social Security Administration.