2015-21045. 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 of 1995, effective October 1, 1995. This notice includes revisions and extensions 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. 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, OLCA, Attn: Reports Clearance Director, 3100 West High Rise, 6401 Security Blvd., Baltimore, MD 21235, Fax: [phone], Email address: [e-mail].

Or you may submit your comments online through www.regulations.gov,, referencing Docket ID Number [SSA-2015-0050].

I. The information collection below is pending at SSA. SSA will submit it 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 October 26, 2015. Individuals can obtain copies of the collection instrument by writing to the above email address.

Response to Notice of Revised Determination—20 CFR 404.913-404.914, 404.992(b), 416.1413-416.1414, and 416.1492(d)—0960-0347. When SSA determines: (1) Claimants for initial disability benefits do not actually have a disability, or (2) current disability recipients' records show their disability ceased, SSA notifies the disability claimants or recipients of this decision. In response to this notice, the affected claimants and disability recipients have the following recourse: (1) They may request a disability hearing to contest SSA's decision and (2) they may submit additional information or evidence for SSA to consider. Disability claimants, recipients, and their representatives use Form SSA-765 to accomplish these two actions. If respondents request the first option, SSA's Disability Hearings Unit uses the form to schedule a hearing; ensure an interpreter is present, if required; and ensure the disability recipients or claimants and their representatives receive a notice about the place and time of the hearing. If respondents choose the second option, SSA uses the form and other evidence to reevaluate the claimant's case and determine if the new information or evidence will change SSA's decision. The respondents are disability claimants, current disability recipients, or their representatives.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-765	1,925	1	30	963

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 30 days from the date of this publication. To be sure we consider your comments, we must receive them no later than September 24, 2015. Individuals can obtain copies of the OMB clearance packages by writing to [e-mail].

1. Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits—20 CFR 404.2015 and 416.615—0960-0024. SSA appoints a representative payee in cases where we determine beneficiaries are not capable of managing their own benefits. In those instances, we require medical evidence to determine the beneficiaries' capability of managing or directing their benefit payments. SSA collects medical evidence on Form SSA-787 to (1) determine beneficiaries' capability or inability to handle their own benefits, and (2) assist in determining the beneficiaries' need for a representative payee. The respondents are the beneficiary's physicians, or medical officers of the institution in which the beneficiary resides.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-787	120,000	1	10	20,000

2. State Supplementation Provisions: Agreement; Payments—20 CFR 416.2095-416.2098, 20 CFR 416.2099—0960-0240. Section 1618 of the Social Security Act (Act) requires those states administering their own supplementary income payment program(s) to demonstrate compliance with the Act by passing Federal cost-of-living increases on to individuals who are eligible for state supplementary payments, and informing SSA of their compliance. In general, states report their supplementary payment information annually by the maintenance-of-payment levels method. However, SSA may ask them to report up to four times in a year by the total-expenditures method. Regardless of the method, the states confirm their compliance with the requirements, and provide any changes to their optional supplementary payment rates. SSA uses the information to determine each state's compliance or noncompliance with the pass-along requirements of the Act to determine eligibility for Medicaid reimbursement. If a state fails to keep payments at the required level, it becomes ineligible for Medicaid reimbursement under Title XIX of the Act. Respondents are state agencies administering supplemental programs.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
Total Expenditures	7	4	60	28
Maintenance of Payment Levels	26	1	60	26
Total	33			54

3. Continuation of Supplemental Security Income Payments for the Temporarily Institutionalized—Certification of Period and Need to Maintain Home—20 CFR 416.212(b)(1)—0960-0516. When SSI recipients (1) enter a public institution or (2) enter a private medical treatment facility with Medicaid paying more than 50 percent of expenses, SSA must reduce recipients' SSI payments to a nominal sum. However, if this institutionalization is temporary (defined as a maximum of three months), SSA may waive the reduction. Before SSA can waive the SSI payment reduction, the agency must receive the following documentation: (1) A physician's certification stating the SSI recipient will only be institutionalized for a maximum of three months, and (2) certification from the recipient, the recipient's family, or friends, confirming the recipient needs SSI payments to maintain the living arrangements to which the individual will return post-institutionalization. To obtain this information, SSA employees contact the recipient (or a knowledgeable source) to obtain the required physician's certification and the statement of need. SSA does not require any specific format for these items, so long as we obtain the necessary attestations. The respondents are SSI recipients, their family or friends, as well as physicians or hospital staff members who treat the SSI recipient.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
Physician's Certifications and Statements from Other Respondents	60,000	1	5	5,000

4. Request for Deceased Individual's Social Security Record—20 CFR 402.130—0960-0665. When a member of the public requests an individual's Social Security record, SSA needs the name and address of the requestor as well as a description of the requested record to process the request. SSA uses the information the respondent provides on Form SSA-711, or via an Internet request through SSA's electronic Freedom of Information Act (eFOIA) Web site, to (1) verify the wage earner is deceased and (2) access the correct Social Security record. Respondents are members of the public requesting deceased individuals' Social Security records.

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

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
Internet Request through eFOIA	49,800	1	7	5,810
SSA-711 (paper)	200	1	7	23
Total	50,000			5,833

Cost Burden *:

In addition, SSA charges fees to the respondent for this information. The following charts shows the fees per transaction based on the information the respondent provides on the SSA-711 (or in eFOIA):

Modality of completion	Information provided (or not provided)	Cost per transaction
SSA-711 (paper)	SSN of decedent is not provided	$29
SSA-711 (paper)	SSN of decedent is provided	27
eFOIA (Internet)	SSN of decedent is not provided	18
eFOIA (Internet)	SSN of decedent is provided	18

* As these costs are dependent on the respondent's provided information, we charge them on an as needed basis, and cannot provide a total annual estimate of the cost burden. We do not know whether the respondent provided the decedent's SSN until we manually review and process each SSA-711.

5. Electronic Health Records Partnering Program Evaluation Form—20 CFR 404.1614, 416.1014, 24 CFR 495.300-495.370—0960-0798. 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 Health IT Partner Program Assessment—participating Facilities and Available Content 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 evaluate potential partners (i.e., healthcare providers and organizations) on (1) the accessibility of 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: Revision of an OMB-approved information collection.

Modality of completion	Number of respondents	Frequency of response	Average burden per response (minutes)	Estimated total annual burden (hours)
SSA-680	30	1	5	150

Dated: August 20, 2015.

Naomi R. Sipple,

Reports Clearance Officer, Social Security Administration.