Supporting Statement 0960-0323

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. Introduction/Authoring Laws and Regulations – To reduce Medicaid costs, Medicaid state agencies identify third-party insurers liable for medical care or services for Medicaid recipients. Under 42 CFR433.136-433.139, Medicaid state agencies 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 Social Security Administration (SSA) 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.

2. Description of Collection - Under such 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. Because disclosure of third-party liability information is a condition of Medicaid eligibility, 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 recipients. SSA performs these activities and receives 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 SSI claimants and recipients.

3. Use of Information Technology to Collect the Information - SSA usually collects the information on the SSA-8019 through the electronic system, the Modernized SSI Claims System (MSSICS). We record more than 99 percent of respondents 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 personnel complete the third party liability information, when necessary. SSA electronically transmits the third party liability information to the state Medicaid agency.

Although we do not require the state to complete any part of the form, there are situations when SSA will mail a paper SSA-8019 to the state third-party liability agency. These situations include:

• Non-MSSICS initial claims;

• 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. Why We Cannot Use Duplicate Information - The nature of the information we are collecting and the manner in which we are collecting it precludes duplication. SSA does not use another collection instrument to obtain similar data.

5. Minimizing Burden on Small Respondents - This collection does not affect small businesses or other small entities

6. Consequences of Not Collecting Information or Collecting it Less Frequently – Since we only collect the information when we need to confirm third-party liability information, we cannot collect the information less frequently. There are no technical or legal obstacles to burden reduction.

7. Special Circumstances - There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.

8. Solicitation of Public Comment and Other Consultations with the Public - SSA published a 60-day advance Federal Register Notice on January 31, 2012 at 77 FR 4854, and we received no public comments. SSA published the second Notice on April 10, 2012 at 77 FR 21616. If we receive any public comments in response to the second Notice, we will forward them to OMB. SSA did not consult members of the public in the development of this form.

9. Payment or Gifts to Respondents - SSA provides no payments or gifts to the respondents.

10. Assurance of Confidentiality - 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. Justification for Sensitive Questions - The information collection does not contain any questions of a sensitive nature.

12. Estimates of Public Reporting Burden - Approximately 67,034 respondents take 5 minutes each to complete Form SSA-8019-U2 each year. Accordingly, the burden is 5,586 hours. We record more than 99 percent of the responses using MSSICS. The total burden represents burden hours, and we did not calculate a separate cost burden.

Collection Instrument	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)
SSA-8019 Paper form	130		5	11
Intranet version (MSSICS)	66,904		5	5,575
Totals	67,034			5,586

13. Annual Cost to the Respondent - There is no known cost burden on the respondents.

14. Annual Cost to the Federal Government - The annual cost to the Federal Government is approximately $531,694. This estimate includes operational expenses, such as overhead costs, equipment and systems costs, calculation of staff hours and salaries, and other expenses that we may incur for collecting the information.

15. Program Changes or Adjustments to the Information Collection Request - 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.

16. Plans for Publication Information Collection Results - SSA will not publish the results of the information collection.

16. Displaying the OMB Approval Expiration Date - We will not publish the OMB approval expiration date for the paper version of Form SSA-8019-U2. OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public-use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval, thus avoiding Government waste.

For the Intranet version of Form SSA-8019-U2, SSA is not requesting an exception to the requirement to display the OMB approval expiration date.

18. Exception 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).

B. Collections of Information Employing Statistical Methods

SSA does not use statistical methods for this information collection.