Emergency Request Letter -0960-0269

October 19, 2006

Karen Y. Matsuoka

Office of Information and Regulatory Affairs, OMB

Room 10235, New Executive Office Bldg.

725 17^th St. NW

Washington, D.C. 20503

October 19, 2006

Dear Ms. Matsuoka:

Attached is an Emergency Information Collection Request for a revision to an existing OMB-approved information collection, form HA-501 (OMB No. 0960-0269). Because we must begin using the collection by December 2006, we ask that you grant emergency clearance by Thursday, November 2, 2006. A clearance date of November 2, 2006 would allow for the required two-week public comment period, since the emergency Federal Register Notice published today, 10/19/2006. Below we provide the justification for our emergency request.

Section 811 of the Medicare Modernization Act of 2003 (Public Law 108-173) established a new Medicare Part B premium subsidy reduction, otherwise known as an Income-Related Monthly Adjustment Amount (IRMAA), which is effective January 2007 for beneficiaries who fall within the income brackets specified in the law. Although the Centers for Medicare and Medicaid Services (CMS) will coordinate the changes to the Medicare Part B program, SSA will make the actual determinations about which beneficiaries will have to pay the IRMAA and the amount of the IRMAA.

Medicare Part B beneficiaries who want to appeal SSA’s decision have a right to request a hearing before an Administrative Law Judge in the Department of Health and Human Services. However, they need an information collection tool to request such a hearing. We would like to expand the scope of existing form HA-501 (OMB No. 0960-0269), the Request for Hearing by Administrative Law Judge, so that we can use it for Medicare Part B beneficiaries. The form is currently used by beneficiaries to file a request for a hearing on Social Security benefits; the use of the form for Medicare Part B is a new use and will increase the number of respondents and the burden. We will not, however, be changing any questions or adding new ones to the collection.

SSA expects to make its first IRMAA redeterminations for Medicare Part B beneficiaries in December 2006. If beneficiaries wish to contest these initial redetermination decisions, they can then use form HA-501 to request an appeals hearing. We therefore need the re-cleared HA-501 to be approved by December 2006. Please note that we were not able to pursue re-clearance of this form earlier because we were in negotiations with HHS about how this process should be handled.

The Emergency Information Collection Request is attached to this letter. Please contact me with any questions. Thank you in advance for your expeditious handling of this matter.

Sincerely,

/s/

Elizabeth A. Davidson

Reports Clearance Officer

Social Security Administration