Supporting Statement for Form SSA-8019-U2
Third Party Liability Information Statement
42 CFR 433.136-433.139
OMB No. 0960-0323
A. Justification
1. Identification of sources of third party insurance liable for medical care or services for Medicaid beneficiaries, which could be used to reduce Medicaid costs, is required under 42 U.S.C. 1396a(a)(25). Medicaid State agencies are required under 42 CFR 433.136-433.139 to obtain this information on Medicaid applications and redeterminations as a condition of Medicaid eligibility. Under 42 U.S.C 1383c(a), States may enter into agreements with the Commissioner of Social Security to make Medicaid eligibility determinations for aged, blind and disabled beneficiaries in those States. Applications for and redeterminations of supplemental security income (SSI) eligibility in jurisdictions with such agreements are also applications and redeterminations of Medicaid eligibility.
The Medicaid State agencies use the information provided to attempt to bill any third parties liable for medical care, support or services for a beneficiary to guarantee that Medicaid remains the payer of last resort. Because disclosure of third party liability information is a condition of Medicaid eligibility, the Social Security Administration (SSA) gathers that information on SSI applications and redeterminations in 32 States and the District of Columbia, which have agreements allowing SSA to make Medicaid eligibility determinations for aged, blind and disabled SSI beneficiaries. SSA performs the activities and gets reimbursement under the terms of a formal agreement with the Centers for Medicare & Medicaid Services (CMS) of the Department of Health and Human Services. The respondents are Supplemental Security Income claimants and receipents.
SSA usually collects the information on this form through the Modernized Supplemental Security Income Claims System (MSSICS), 99% of respondents respond using MSSICS. In MSSICS initial claims and redetermination situations (when there is a change in third party liability coverage or other specific post eligibility changes), SSA field office or PSC personnel are required to complete the third party liability information, when necessary. SSA electronically transmits the third party liability information to the State Medicaid agency.
However, there are situations when a paper SSA-8019 must be completed and mailed to the State third party liability agency. These situations include:
Non-MSSICS initial claims that are allowed;
Non-MSSICS redetermination or post-eligibility action with changes in third party liability circumstances; or
MSSICS claims when complete third party liability information was not available at the time SSA adjudicated the claim.
4. The nature of the information we are collecting and the manner in which we are collecting it preclude duplication. SSA does not use another collection instrument to collect similar data.
5. This collection does not significantly affect a substantial number of small businesses or other small entities
6. Congress made the provision of third party liability information a condition of Medicaid eligibility because it saves significant Federal dollars. Therefore, SSA cannot collect the information less frequently. There are no technical or legal obstacles to burden reduction.
7. There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
8. The 60-day advance Federal Register Notice published on January 26, 2009, at 74 FR 4498, and SSA received no public comments. The second Notice published on
April 07, 2009, at 74 FR 15808. SSA did not consult members of the public in the development of this form.
9. SSA provides no payment or gifts to the respondents.
SSA protects and holds confidential the information it is requesting in accordance with 42 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.
11. The information collection does not contain any questions of a sensitive nature.
12. Approximately 62,834 respondents use Form SSA-8019-U2 per year, 99% of the respondents respond using MSSICS. The estimated average time for each response is 5 minutes, for a total of 5,236 burden hours in the 33 affected jurisdictions. The total burden represents burden hours, and SSA did not calculate a separate cost burden.
13. There is no known cost burden to the respondents.
14. The annual cost to the Federal Government is approximately $464,577. This estimate includes operational expenses, such as SSA overhead costs, equipment and systems costs, calculation of staff hours/salaries costs and other expenses that may incur for collecting the information.
15. SSA based the updated figure of hours on SSA's latest data available for Fiscal Year 2008. The change in hours reflects normal workload variations.
SSA will not publish the results of the information collection.
17. OMB exempted SSA from the requirement to print the OMB approval expiration date 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). OMB granted this exemption so the agency would not have to discontinue using otherwise useable editions of forms with outdated expiration dates. In addition, SSA avoids Government waste, because we will not have to destroy and reprint stocks of forms.
18. 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).
B. Collections of Information Employing Statistical Methods
SSA is not using statistical methods for this collection.
| File Type | application/msword |
| File Title | February 2000 |
| Author | bbenjam |
| Last Modified By | Mandley, Tasha |
| File Modified | 2009-04-08 |
| File Created | 2008-12-24 |