Addendum to the Supporting Statment 0960-0707

Addendum to Supporting Statement for

Medicare Subsidy Quality Review Forms

Forms SSA-9301, -9302, -9303, -9304, -9308, -9310,

-9311, -9312, - 9313, -9314 -8510

OMB No. 0960-0707

SSA is making the following revisions

Change 1: We removed the Office of Quality Performance header and replaced with Office of Quality Review. This change occurs on the SSA-9302, SSA-9303, SSA-9308, SSA-9310, and SSA-9311 through SSA-9314.

Justification 1: We made this language change to conform to our new our name.

Change 2: We are making several non-substantial changes on the SSA-9301.

Notable changes are:

• We removed the Special Procedures question on the Facesheet. We no longer use Special Procedures for our reviews.

• We revised the Family Size Interview and Verification columns to clarify what we need for the household size.

• We removed two statements in the Liquid Resources Conclusion column, as we do not need this information for our reviews.

• We removed references to Lexis-Nexis in the Non-Home Real Property element and replaced with the current provider, Accurint.

• We removed “Resources affected the co-pay/deductible only” in the Total Countable Resources Summary. We no longer need this information for our review.

• We added clarifying language for the Unearned Income (UI) Verification column. In the Conclusion column, a breakdown of UI now mimics what MAPS shows.

• The Earned Income (EI) Interview column adds “Cafeteria Plan” to remind the reviewer to inquire about this plan. In the Conclusion column, the EI is broken into wages and SEI to mimic MAPS.

• We removed No check boxes on the Facesheet, Marital Status, Family Size, Liquid Resources, Non-Home Real Property, Funeral/Burial Expenses, Total Countable Resources Summary, Unearned Income, and Earned Income. We are only interested if the answer is yes for these elements.

Justification 2: We are making the SSA-9301 more user friendly for the reviewer. The meaning of the questions remains the same. The reformatting on the form makes it more straightforward for the reviewer to administer.

Other Minor Revisions to the Collection

SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the forms.