Agency Information Collection Activities: Proposed Request and Comment 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 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.

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 collections 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: 202-395-6974.

(SSA), Social Security Administration, DCFAM, Attn: Reports Clearance Officer, 1338 Annex Building, 6401 Security Blvd., Baltimore, MD 21235, Fax: 410-965-6400.

I. The information collections listed below have been submitted to OMB for clearance. Your comments on the information collections would be most useful if received by OMB and SSA within 30 days from the date of this publication. 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. Application for Help with Medicare Prescription Drug Plan Costs—0960-NEW. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-173; MMA) establishes a new Medicare Part D program for voluntary prescription drug coverage for premium, deductible and cost-sharing subsidies for certain low-income individuals. The MMA stipulates that subsidies must be available for individuals who are eligible for the program and who meet eligibility criteria for help with premium, deductible, and/or co-payment costs. Form SSA-1020, the Application for Help with Medicare Prescription Drug Plan Costs, collects information about an applicant's resources and is used by SSA to determine eligibility for this assistance. The respondents are individuals who are eligible for enrollment in the new program and are requesting assistance with the related costs.

Note:

Since publishing the 60-day Federal Register Notice (69 FR 45879), SSA has decided to conduct a pilot test of form SSA-1020 in March 2005. This test is intended to assist SSA in: (1) determining how eligible individuals will respond to its Part D Subsidy application outreach (scheduled to begin in June 2005) and (2) testing its systems processing of the SSA-1020 application. SSA will use the information to make actual subsidy eligibility determinations. The Agency will conduct the test with approximately 2,000 beneficiaries potentially eligible for Part D cost-sharing subsidies by providing them with copies of form SSA-1020.

Type of Request: New information collection.

Number of Respondents: 5,000,000.

Frequency of Response: 1.

Average Burden Per Response: 35 minutes.

Estimated Annual Burden: 2,916,667 hours.

2. Appeal of Determination for Help with Medicare Prescription Drug Plan Costs—0960-NEW. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; MMA) establishes a new Medicare Part D program for voluntary prescription drug coverage for premium, deductible and cost-sharing subsidies for certain low-income individuals. The MMA stipulates that subsidies must be available for individuals who are eligible for the program and who meet eligibility criteria for help with premium, deductible, and/or co-payment costs. Form SSA-1021, the Appeal of Determination for Help with Medicare Prescription Drug Plan Costs, was developed to obtain information from individuals who appeal SSA's decisions regarding eligibility or continuing eligibility for a Medicare Part D subsidy. The respondents are applicants who are appealing SSA's eligibility or continuing eligibility decisions.

Type of Request: New information collection.

Number of Respondents: 75,000.

Frequency of Response: 1.

Average Burden Per Response: 10 minutes.

Estimated Annual Burden: 12,500 hours.