Supporting Statement 0323 (revised)

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

To reduce Medicaid costs, Medicaid state agencies must identify third party insurers liable for medical care or services for Medicaid beneficiaries. Applications for and redeterminations of Supplemental Security Income (SSI) eligibility in jurisdictions with such agreements are also applications and redeterminations of Medicaid eligibility. Under these agreements, SSA obtains third party liability information using Form SSA-8019, and provides the information to the Medicaid state agencies. The Medicaid state agencies use the information to bill third party 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.

3. Use of Information Technology to Collect the Information

SSA usually collects the information on this form through the Modernized Supplemental Security Income Claims System (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 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.

In accordance with the agency’s Government Paperwork Elimination Act plan, SSA created an intranet version of Form SSA-8019-U2. Based on our data, we estimate approximately 99% of respondents under this OMB number use the electronic version.

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 significantly affect a substantial number of small businesses or other small entities

6. Consequences of Not Collecting Information or Collecting it Less Frequently

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. Special Circumstances

There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with.

8. Solicitation of Public Comment and Other Consultations with the Public

The 60-day advance Federal Register Notice published on April 30, 2015, at 80 FR 24307, and we received no public comments. The 30-day FRN published on

July 1, 2015 at 80 FR 37708. If we receive any comments in response to this Notice, we will forward them to OMB.

Note: The first Federal Register Notice shows incorrect form number for the SSA‑8019-U2. We have corrected for this in the second Notice, in #12 below and on ROCIS.

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

Modality of Completion	Number of Respondents	Frequency of Response	Average Burden Per Response (minutes)	Estimated Total Annual Burden (hours)
SSA-8019-U2 Paper form	200		5	17
Intranet version (MSSICS)	51,381		5	4282
Totals	51,581			4,299

The total burden for this ICR is 4,299 hours. This figure represents burden hours, and we did not calculate a separate cost burden.

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

There has been a decrease in the burden hours. The change in hours reflects normal workload variations, and a decrease in the number of users. Based on the nature and purpose of the form there have been fewer situations where the form has been necessary.

16. Plans for Publication Information Collection Results

SSA will not publish the results of the information collection.

16. Displaying the OMB Approval Expiration Date

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 dates, 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.