05-12980. Agency Information Collection Activities: Emergency Consideration Request

The Social Security Administration (SSA) publishes a list of information collection packages that will require clearance by the Office of Management and Budget (OMB) in compliance with Pub. L. 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.

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 on 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. The information can be mailed and/or faxed to the individuals at the addresses and fax numbers listed below:

(OMB) Office of Management and Budget, Attn: Desk Officer for SSA, New Executive Building, Room 10235, 725 17th St., NW., Washington, DC 20503. Fax: [phone].

(SSA) Social Security Administration, DCFAM, Attn: Reports Clearance Officer, 1333 Annex Building, 6401 Security Blvd., Baltimore, MD 21235. Fax: [phone].

The information collections listed below have been submitted to OMB for expedited Emergency Clearance. SSA is requesting Emergency Consideration from OMB by 07/15/2005. Your comments on the information collections are requested by that date. You can obtain a copy of the OMB clearance packages by calling the SSA Reports Clearance Officer at 410-965-0454, or by writing to the address listed above.

1. Medicare Subsidy Quality Review Case Analysis Forms—20 CFR Part 418(b)(5)—0960—NEW. Under the aegis of the Medicare Modernization Act of 2003, SSA will make Medicare Part D subsidy determinations and will work with the Centers for Medicare and Medicaid Services to administer the subsidy. The subsidy determination is based on applicants' answers to questions about categories such as household size, income, and assets. 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 self-reported information on form OMB No. 0960-0696. In this system, SSA will conduct phone interviews with selected applicants and will confirm information such as household size, income, and assets.

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.

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-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-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					16,416

Total Estimated Annual Burden: 16,416 hours.

Dated: June 24, 2005.

Craig Hartson,

Acting Reports Clearance Officer, Social Security Administration.