SUPPORTING STATEMENT FOR FORM SSA-54
Authorization for SSA to disclose tax information for your appeal of your medicare part b income-related monthly adjustment premium amount
20 CFR 418.1350
OMB No. 0960-NEW
Justification
Circumstances which Make the Collection of Information Necessary and Legal/Administrative Justification for Collecting the Information.
Section 1839(i) of the Social Security Act established a new Medicare Part B premium subsidy reduction which results in higher Medicare Part B premiums for enrollees with income above a stated threshold. Currently, the government pays 75% of the Part B standard premium, and the beneficiary pays the remaining 25%. SSA will receive tax data from the Internal Revenue Service (IRS) and if the tax amount exceeds the threshold, an Income Related Monthly Adjustment Amount (IRMAA) will be charged in addition to the standard monthly Medicare Part B premium.
If Medicare beneficiaries who must pay IRMAA disagree with the decision, they may request an appeal, known as a “reconsideration,” from SSA. If beneficiaries are unsatisfied with SSA’s reconsideration decision, they may request an appeals hearing before an administrative law judge (ALJ) as stated in section 20 CFR 418.1350. To make this request, beneficiaries complete form OMB No. 0960-0269 (the Request for Hearing by ALJ). Once SSA receives this form, SSA will forward it, together with relevant beneficiary information, to the Department of Health and Human Services (HHS) who will conduct a hearing.
At the hearing, HHS ALJs need the relevant beneficiary tax data to determine if SSA correctly computed the beneficiary’s IRMAA. Since section 26 USC 6103(a) of the U.S. Code prohibits SSA from forwarding the beneficiary tax information received from IRS, SSA must obtain authorization from the beneficiary to release this data to HHS. Currently, SSA uses an IRS disclosure form, IRS Form 8821, to collect this information (approved for SSA’s use as OMB No. 0960-0738). SSA has developed its own form, form SSA-54, which we will use to replace IRS Form 8821. This ICR is for the new form SSA-54.
How, By Whom, and For What Purpose the Information Will Be Used.
SSA will use this form when there are appeals of income-related Medicare Part B premiums to an HHS Administrative Law Judge. We will post a copy of the form together with instructions explaining where beneficiaries should send the completed form and clarifying how to complete the form. We will use the form to obtain beneficiary approval to forward tax data to HHS, who can then schedule an appeals hearing and any further appeal if the beneficiary pursues it.
Describe the Use of Information Technology for this Collection.
The form and its instructions will be posted on SSA’s website in PDF format which the beneficiary can print, complete, and mail manually. Since this form will generate a relatively low volume of usage, it will not be implemented electronically under SSA’s Government Paperwork Elimination Act plan.
Describe Efforts to Identify Duplication.
The information that will be collected by this form is currently being collected by another form, IRS Form 8821 (OMB No. 0960-0738; see above for details). However, that form will be discontinued once form SSA-54 is approved, so there will be no actual duplication of information.
Impact on Small Businesses or Other Small Entities.
This collection does not impact small businesses or entities.
Impact of Not Conducting the Information Collection or Conducting It Less Frequently.
Since the form we are currently using to obtain beneficiary authorization, IRS Form 8821, was only approved by OMB on a temporary basis, SSA needs a new form for this purpose. If the information were not collected, SSA would be unable to release beneficiary tax data to HHS, impeding a beneficiary’s legal right to an appeal. Since the information will only be collected once, it cannot be collected less frequently.
There are no technical or legal obstacles that prevent burden reduction.
Any Special Circumstances Surrounding this Information Collection.
There are no special circumstances that would cause this information collection to be conducted in a manner inconsistent with 5 CFR 1320.5.
Federal Register Notice Publication
The advance 60-day Federal Register Notice was published on August 7, 2007, at 72 FR 44211, and SSA received no public comments. The 30-day Federal Register Notice will be published on Wednesday, October 10, 2007 at 72 FR 57629. We will forward any public comments we receive in response to this Notice to OMB.
There have been no outside consultations with members of the public.
Payment or Gifts to the Respondents
SSA provides no payment or gifts to the respondents.
Assurances of Confidentiality
The information requested is protected and held confidential in accordance with U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974), and OMB Circular No. A-130.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
An estimated 6,000 Medicare Part B beneficiaries will take 15 minutes to read the relevant instructions and complete this form each year. The total annual burden of 1,500 hours is reflected as burden hours, and no separate cost burden has been calculated.
Annual Cost to the Respondents
There is no known cost burden to the respondents.
Annual Cost to the Federal Government
The cost to the Federal Government for processing these forms has already been reported in previous ICRs as part of the cost of processing appeals requests.
Change to Reporting Burden
Although this is a new form, it will replace an existing form with the same burden (IRS Form 8821). Therefore, there will be no actual change to the public reporting burden.
Plans for Publication of Results of Information Collection
The results of the information collection will not be published.
Request not to Display the OMB Expiration Date
OMB has granted SSA an exemption from the requirement that the expiration date for OMB approval be printed on its program forms. SSA produces millions of public-use forms, many of which have a life cycle longer than that of an OMB approval. SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis). This exemption was granted so that otherwise useable editions of forms would not be taken out of circulation because the expiration date had been reached. In addition, Government waste has been avoided because stocks of forms will not have to be destroyed and reprinted.
This is a PDF-only form that will be used for an indefinite period of time, and as such is exempt from the requirement to display the OMB expiration date.
Exceptions to Certification Statement
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).
Collections of Information Employing Statistical Methods
Statistical methods are not used for this information collection.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR SSA GUIDANCE FOR USE OF THE TAX INFORMATION AUTHORIZATION FORM |
| Author | Faye |
| Last Modified By | 666429 |
| File Modified | 2007-10-23 |
| File Created | 2007-10-15 |