E5-7111. Agency Information Collection Activities: Proposed Request

The Social Security Administration (SSA) publishes a list of information collection packages that requires clearance by the Office of Management and Budget (OMB) in compliance with Public Law 104-13, the Paperwork Reduction Act of 1995, effective October 1, 1995. The information collection packages that may be included in this notice are for new information collections, approval of existing information collections, revisions to OMB-approved information collections, and extensions (no change) of OMB-approved information collections.

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. Written comments and recommendations regarding the information collection(s) should be submitted to the OMB Desk Officer and the SSA Reports Clearance Officer.

(OMB), Office of Management and Budget, Attn: Desk Officer for SSA. Fax: [phone].

(SSA), Social Security Administration, DCFAM, Attn: Reports Clearance Officer. Fax: [phone]. E-mail: [e-mail].

The information collection listed below is pending at SSA and will be submitted to OMB within 60 days from the date of this notice. Therefore, your comments should be submitted to SSA within 60 days from the date of this publication. You can obtain a copy of the collection instrument by calling the SSA Reports Clearance Officer at 410-965-0454 or by e-mailing or faxing your request to the above e-mail address and fax number.

Medicare Subsidy Quality Review Case Analysis Forms—20 CFR 418(b)(5)—0960-0707

Under the aegis of the Medicare Modernization Act of 2003, SSA will make Medicare Part D subsidy determinations for the Medicare Prescription Drug program for Medicare beneficiaries with limited income and resources. The subsidy determination is based on applicants' answers to questions about household size, income, and resources. This information is self-reported by applicants using form OMB No. 0960-0696 (SSA-1020), and thus, SSA needs a way to determine if this form is being completed accurately and completely and a way to validate its determination decisions. To this end, SSA will use the new Medicare Quality Review system to check the accuracy of the determination. In this system, SSA will conduct phone interviews with selected applicants and will confirm information such as household size, income, and resources. A questionnaire and several other forms will be used as part of the Medicare Quality Review System. The collection instruments, their descriptions, and burden information are listed in the table below.

Note:

This Notice is for the permanent approval of this collection, which was cleared by OMB temporarily through February 2006 as an emergency information collection.

Type of Request: Extension of a currently approved information collection.

Form number and name	Description of form	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated annual burden (hours)
SSA-9301 (Medicare Subsidy Quality Review Case Analysis Questionnaire)	Telephone questionnaire which will be administered by SSA employees to applicants for Medicare Part D Subsidy. Includes questions about family size, marriage, income, assets, etc	10,000	1	35	5,833
SSA-9302 (Notice of Quality Review Acknowledgement Form for those with Phones)	After receiving notice of the scheduled date/time of the telephone questionnaire, Part D applicants will return this form confirming their availability for the interview and making note of any special needs for the call	10,000	1	15	2,500
SSA-9303 (Notice of Quality Review Acknowledgement Form for those without Phones)	Same as for SSA-9302, except used by participants without phones or whose phone numbers are not known by SSA. On form SSA-9303, however, participants confirm receipt of the letter and are asked to call SSA on a specified date	1,000	1	15	250
SSA-9304 (Checklist of Required Information)	This checklist, which accompanies forms SSA-9302 and SSA-9303, is a list of the documentation respondents are supposed to have prepared when SSA calls them to conduct the Quality Review phone interview. Their burden is accounted for in the burdens for forms SSA-9302 and SSA-9303
SSA-9308 (Request for Information)	Form which SSA will send to various third parties to obtain/confirm information reported by beneficiaries	20,000	1	15	5,000
SSA-9310 (Request for Documents)	Following the phone interview, SSA sends this notice to the participants advising them of the documents they must return to SSA	10,000	1	5	833
SSA-9309 (Life Insurance Verification Form)	Form completed by insurance companies confirming type, face value, cash surrender value and dividends for insurance policies of applicants for Medicare Part D subsidy	8,000	1	15	2,000
SSA-8510 (Authorization to the Social Security Administration to Obtain Personal Information)	Beneficiaries give their permission for SSA to contact third parties to obtain/confirm information	10,000	1	5	833
Total		69,000			17,249

Total Estimated Annual Burden: 17,249 hours.

Dated: December 2, 2005.

Elizabeth A. Davidson,

Reports Clearance Officer, Social Security Administration.