Third Party Liability Information Statement

Forms and Documents

Document Name	Status
Form SSA-8019-U2 Third Party Liability Information Statement Form	Modified
Supporting Statement 0960-0323.doc Supporting Statement A	2012-04-16
Addendum.doc Supplementary Document	2012-07-19

IC Document Collections

IC ID	Document Title	Status
43701	Third Party Liability Information Statement Other-MSSIC Screens	Modified
189371	Third Party Liability Information Statement Form	Modified

ICR Details

OMB Control No: 0960-0323	ICR Reference No: 201201-0960-008
Status: Historical Active	Previous ICR Reference No: 200812-0960-014
Agency/Subagency: SSA	Agency Tracking No:
Title: Third Party Liability Information Statement
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/02/2012
	Date Received in OIRA: 05/02/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2015	36 Months From Approved	10/31/2012
Responses	67,034	0	62,833
Time Burden (Hours)	5,586	0	5,236
Cost Burden (Dollars)	0	0	0

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Abstract: Medicaid state agencies must identify third party insurers liable for medical care or services for Medicaid beneficiaries; this reduces Medicaid costs. Regulations at 42 CFR 433.136–433.139 require Medicaid state agencies to obtain this information on Medicaid applications and redeterminations as a condition of Medicaid eligibility. 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 applications and redeterminations of Medicaid eligibility. Under these agreements, SSA obtains third party liability information using Form SSA- 8019 and provides that information to the Medicaid state agencies. The Medicaid state agencies use the information to bill third parties liable for medical care, support, or services for a beneficiary to guarantee that Medicaid remains the payer of last resort. The respondents are SSI claimants and recipients.

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Authorizing Statute(s): US Code: 42 USC 1396a Name of Law: Social Security Act
   US Code: 42 USC 1383c Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 4854	01/31/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 21616	04/10/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Third Party Liability Information Statement
Third Party Liability Information Statement	SSA-8019-U2	Third Party Liability Information Statement

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	67,034	62,833	0	0	4,201	0
Annual Time Burden (Hours)	5,586	5,236	0	0	350	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: When we last cleared this information collection in 2008, the burden was 5,236 hours. The change in hours reflects normal workload variations and an increase in the number of respondents.

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Annual Cost to Federal Government: $531,694

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/02/2012

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