Addendum to the Supporting Statement for Form SSA-8001-BK
Application for Supplemental Security Income (SSI)
(Deferred or Abbreviated)
OMB No. 0960-0444
Revisions to the Collection Instrument
Below is a summary of changes for SSA-8001-BK. We are making these revisions to update minor changes in policy. We are asking for some questions to be renumbered in the proposed SSA-8001 document, due to the revisions OMB recently approved on 9/12/17. We are not making any required changes for the SSI Claim System web pages.
Change #1: On page 1, in the Type of Claim section, we are adding parentheses for the “s” in parents for the selection “Child with Parents.”
From: Child with Parents
To: Child with Parent(s)
Justification #1: We are updating the word “Parents” to show Parent(s) to allow for the selection to apply to one parent or two parents.
Change #2: On page 1, Question #8, we are adding new questions (d), (g) and (h). In addition, the two questions (in bold) which are currently unlabeled, we will assign the letters (e) and (f) to these two existing questions. We are making revisions as follows:
d) Are you married? Yes , complete (e) and (f) _____________
No, Go to (g)
(e) Date of Marriage (month, day,year)
(f) Are you and your spouse living together? Yes No
If no, date you began living apart
(g) Are you and another person living together in the same household and presenting to others or the community as a married couple?
Yes, provide the date holding out began (month, day, year) _____ Go to (h)*
No Go to #9
(h)* Other person’s name (first, middle initial, last) _________
Other person’s social security number_____________*Use SSA-4178 to develop the holding out relationship.
Justification #2: The SSA-8001-BK does not have the “holding out” question. It appears that the holding out question was never present on this form. The Holding Out page of the SSI Claim System web page collects the information about the possible holding out relationship(s) of the person. It also collects the decision about a holding out relationship. The information collected on the Holding Out page is shared data among all claims where the person’s SSN is active.
The holding out question is not mandatory to answer in the SSI Claim System but our policy requires SSA staff to ask that question to an individual filing for SSI benefits when an individual answers “No” to the marriage question. The public may not know that we may consider a couple as a “couple” even if they are not legally married.
At the initial claim, we establish the record as an eligible individual or an eligible individual with an ineligible spouse or an eligible couple. When we ask” are you married” it is likely that the individual assumes legally married only and only documents the legal marriage information. When we ask an SSI individual if they are “holding themselves out” and the answer is “yes,” the SSI Claim System will put the appropriate screens in the path for SSA staff to complete. Currently, the staff interviewers develop the holding relationship on the SSA-4178.
We are adding this question should to the paper SSA-8001-BK application, as well, as we already added it to the SSI Claims System version. In addition, we also instruct staff to complete the SSA-4178 to develop the holding out relation if the respondent answers “yes” to the question. In the SSI Claim System, we refer to married respondents as “the spouse,” and for respondents “holding out” as married, we refer to them as the “other person.” On the paper SSA-8001-BK application, we only ask for the “spouse’s” name. Since “holding out” is part of our policy we are now adding it to the
Change #3: On page 2, Question 12a, we are adding to the existing question to determine if work is limited because of illnesses, injuries, or conditions. We are making the following changes:
From: Are you unable to work because of illnesses, injuries, or conditions?
To: Are you unable to work or is your work limited because of illnesses, injuries, or conditions?
Justification #3: We are adding to the existing question to capture claimants whose work may be limited because of illnesses, injuries, or conditions.
Change #4: On page 2, we are removing Question 12c: “What are your illnesses, injuries or conditions?” “You” “Your Spouse.”
Justification #4: It is no longer necessary for respondents to complete this question. The SSA-3368 (0960-0579) requests the same information; therefore, we are removing it to avoid duplication of collection.
Change #5: On page 2, we are removing Question 12f: “What are the child’s disabling illnesses, injuries or conditions?”
Justification #5: It is no longer necessary for respondents to complete this question. The SSA-3820 (0960-0577) requests the same information, therefore we are removing it to avoid duplication of collection.
Change #6: On page 2: We are adding two new questions (Question 12c and 12f:) to capture claimants and children who may be blind or have low vision.
New question: 12c. Are you blind or do you have low vision even with glasses or contacts? You Your Spouse Yes, go to d No, go to d
New question: 12f. Is the child blind or does he or she have low vision even with glasses or contacts? Yes, go to g No, go to g
Justification #6: There are special rules for people who are blind or have low vision. We are adding low vision to the blind question to capture claimants who may not consider themselves blind, but have a visual acuity that meets the statutory blindness requirements.
Change #7: On page 2, Question #12(d): We are updating the language to include the term “stepparent” (as in we did in Question 12(g)):
From: If you were unable to work because of illnesses, injuries, or conditions before age 22, do you have a parent who is age 62 or older, unable to work because of illnesses, injuries, or conditions or deceased?
To: If you were unable to work because of illnesses, injuries, or conditions before age 22, do you have a parent or stepparent who is age 62 or older, unable to work because of illnesses, injuries, or conditions or deceased?
Justification #7: We are making this language change for consistency with the terminology on the form and to align with question 12 (g).
Change #8: On page 3, Question 13d: We are rearranging the order of the current immigration status for You and Your Spouse:
From:
1.Amerasian Immigrant
2.Lawful Permanent Resident
3. Refugee
4. Asylee
5. Conditional Entrant
6. Parolee for One YEAR
7. Cuban/Haitian Entrant
8. Deportation/Removal Withheld
9. Other
To:
1.Amerasian Immigrant
2.Asylee
3.Conditional Entrant
4.Cuban/Haitian Entrant
5.Deportation/Removal Withheld
6.Lawful Permanent Resident
7.Parolee for One YEAR
8.Refugee
9. Unknown/Other
Justification #8: We rearranged the order of questions in this list for You and Your spouse to match order in the SSI Claims System.
Change #9: On page 5, Question 19: We are revising the Applicant’s mailing address section to include the collection of information for a foreign address (if applicable):
From:
Claimant’s Mailing Address (Number & Street, Apt. No. P.O. Box, Rural Route)
City and State ZIP Code Name of County(if any) in which you live
To:
Claimant's Mailing Address (Number & Street, Apt. No., P.O. Box, or Rural Route)
City and State (U.S.) ZIP Code Name of County (if any) in which you live State/Province/Region (Foreign) Postal Code Country
Justification #9: When collecting foreign address information, we give the user the option to select the Country from the drop down menu on the Supplemental Security Income Application web page of the SSI Claim System. In addition, the State/Province/Region and Postal code is additional input on this screen for foreign addresses. We are updating the paper application form to align with the Supplemental Security Income Application web page of the SSI Claim System.
Change #10: On page 5, Question 22: We are revising the Residence’s address section to include the collection of information for a foreign address (if applicable):
From:
Claimant's Residence Address
City and State ZIP Code Name of County(if any) in which you live
To:
Claimant's Residence Address (If different from applicant's mailing address)
City and State ZIP Code County
State/Province/Region (foreign) Postal Code Country
Justification #10: When collecting foreign address information, we give the user the option to select the Country from the drop down menu on the Supplemental Security Income Application web page of the SSI Claim System. In addition, the State/Province/Region and Postal code is additional input on this screen for foreign addresses. We are updating the paper application form to align with the Supplemental Security Income Application web page of the SSI Claim System.
Change #11: On page 6, Question #25: We are rearranging the order of the current list of Resources questions, and adding additional resources to the list (i.e., Business Equipment; Achieving a Better Life Experience (ABLE) Account; Financial Institution Account; Stock, Bond or Mutual Fund; Promissory Note, Loan, or Property Agreement; Burial Fund; Burial Space or Related Item):
From:
Trusts
Vehicles
Property other than the home you live in
Savings, checking accounts, stocks, bonds
Cash at home
Items held for potential value or investment
Insurance policies
Other items that can be turned into cash.
To:
Trust.
Vehicle.
Real Property Other Than Home.
Business Equipment.
Achieving a Better Life Experience (ABLE) Account.
Financial Institution Account.
Cash.
Stock, Bond or Mutual Fund.
Promissory Note, Loan, or Property Agreement.
Items Held for Potential Value or Investment.
Life Insurance.
Burial Fund.
Burial Space or Related Item.
Other Resource
Justification #11: We rearranged the order of items in this list, and added the additional items, to match order in the SSI Claims System. This will make it easier for the field office technicians to transcribe the information.
Change #12: On page 6, Question #25: We are adding another Resource (i) to the list of items:
Add: Achieving a Better Life Experience (ABLE) account.
You: Yes No Your Spouse: Yes No
Justification #12: We also ask this question on the SSI Claim System Resource Selection web page. We are updating the paper application form to align with the SSI Claim System.
Change #13: On page 6, Question 26: We are updating the terminology for mother and father:
From:
Mother's Answer
Father's Answer
To:
Parent 1’s answer
Parent 2”s answer
Justification #13: We are changing “Mother’s answer/Father’s answer” to “Parent 1’s answer/Parent 2’s answer,” to be consistent with the terminology in Questions 5(b), 5(c), 9(c), and 9(d).
Change #14: On page 8, we are updating the Part 5 header:
From:
PART 5 - SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)
To:
PART 5- POTENTIAL ELIGIBILITY FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)/MEDICAL ASSISTANCE
Justification #14: We are updating the header to clarify the questions that are shown in Part 5.
Change #15: On page 8, Question 32: We are adding new question 32 a, b, c regarding Medicaid:
#32.
You may be eligible for Medicaid. However, you must help your State identify other sources that pay for medical care. Also, you must give information to help the State get medical support for any child(ren) who is your legal responsibility. This includes information to help the State determine who a child's parent is. If you want Medicaid, you must agree to allow your State to seek payments from sources, such as insurance companies, that are available to pay for your medical care. This includes payments for medical care for you or any person who receives Medicaid and is your legal responsibility. The State cannot provide you Medicaid if you do not agree to this Medicaid requirement. If you need further information, you may contact your Medicaid Agency. |
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(a) Do you agree to assign your rights (or the rights of anyone for whom you can legally assign rights) to payments for medical support and other medical care to the State Medicaid agency? |
You YES NO Go to (b) Go to #33 |
Your Spouse, if filing YES NO Go to (b) Go to #33 |
(b) Do you, your spouse, parent or stepparent have any private, group, or governmental health insurance that pays the cost of your medical care? (Do not include Medicare or Medicaid.) |
YES NO Go to (c) Go to (c) |
YES NO Go to (c) Go to (c) |
(c) Do you have any unpaid medical expenses for the 3 months prior to the filing date month? |
YES NO Go to #33 Go to #33 |
YES NO Go to (c) Go to (c)
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Justification #15: Technical ineligibility for SSI may not mean ineligibility for Medicaid (i.e. some states may have expanded Medicaid eligibility under the Affordable Care Act). Page 1 of the SSA-8001-BK states:
“I am/We are applying for Supplemental Security Income and any federally administered state supplementation under Title XVI of the Social Security Act, for benefits under other programs administered by the Social Security Administration and where applicable, for medical assistance under Title XIX of the Social Security Act.”
Therefore, we are adding in this new question to help determine eligibility for Medicaid.
Change #16: On page 9, Question #33: We are adding the following question (b):
(b) Have you ever served as representative payee for a Social Security beneficiary or SSI claimant? Yes No
Justification #16: When we decide to impose an administrative sanction, and the individual is not currently entitled or eligible for either Title II or Title XVI benefits, we must defer the sanction period. The sanction period cannot begin until the person becomes entitled or eligible for a payment under either Title II or Title XVI. Revising Form SSA-8001-BK to include this question helps us obtain information that will allow us to sanction individuals in deferred status.
Change #17: On pages 8-10: We are renumbering questions 33-38 and renumbering all “Go to #’s.”
Justification #17: Due to the addition of question #32, we are renumbering questions 33-38 and the Go to #’s on the SSA‑8001-BK to ensure the numbering remains consistent.
Revisions to the Collection Instruments – SSA-8001-BK PCS Screens:
Background:
The Social Security Administration (SSA) administers benefits under Title II (Retirement, Survivors and Disability), Title XVI (Supplemental Security Income) and Title XVIII (Medicare Part A) which an individual may be eligible to receive concurrently or consecutively. Filing for one benefit may require or restrict the filing of another benefit under the same or different title. When an individual requests to file for one benefit, the SSA employee (technician) must identify other benefits for which the individual may be eligible so the individual can make an informed filing decision.
Prior to taking a Title II, Title XVI or Title XVIII application, technicians may ask a series of questions to determine the benefit type(s) (i.e. Retirement, Disability, Widow, etc.); systems (Title II or Title XVI claims system); claim type (i.e. abbreviated, deferred, or full), and may request Social Security Numbers (SSN) for taking a claim. We refer to the discussion the technician has with an individual before filing a claim as a pre-claim interview. In most cases, the technicians write down the information they collect, and use various SSA systems to determine eligibility and benefit amounts. Since the questions they asked are part of our OMB-approved forms, we already account for them under their associated OMB Control Numbers.
In response to the IT Modernization initiative, SSA is creating the Preliminary Claims System (PCS) for technicians to use when conducting a pre-claim interview. The PCS includes questions that:
Generate alerts if the pre-claim interview is an exclusion for using PCS (Screen package pages 6-7, 9-11 and 13);
Identify all Title II potential entitlements (Screen package page 68);
Calculate benefit amounts for Title II potential entitlements (Screen package, page 68);
Obtain intent to file for SSI when applicable (Screen package, pages 63 and 67), and
Assist technicians in determining the type of SSI claim to obtain (i.e. abbreviated, deferred, or full) (Screen package – pages 64-66).
The majority of the PCS questions are static with some that have follow-up questions
based on the individual’s response. At the end of the interview, the technician prints a summary of potential Title II entitlements; benefit amounts; and other filing considerations to review with the individual, and annotates the PCS with the filing decision (i.e. File now, Does not want to file, Set up Appointment or Issue Closeout). (We show this screen in our PCS screen package – pages 69-70.)
Based on the filing decision, the PCS provides instructions or links for accessing the Title II and Title XVI claims systems to take a claim, or the 800 Number System for scheduling an appointment or issuing a closeout notice when applicable. (We show this in our PCS screen package – pages 71-74.)
Most of the questions mirror Title II or Title XVI application questions (see PCS questions document). Data collected in PCS will propagate into the appropriate claims system if the individual decides to file. If the individual elects not to file, we temporarily store the information collected in PCS’s database pursuant to the National Archives and Records Administration approved temporary retention schedules, as described in the September 12, 2018 reviewed agency Records Management Questionnaire for the IT Mod – Title II Initial Claims Process. SSA will also use the information we collect and store in PCS for Management Information purposes.
Upon OMB’s approval, SSA will release a limited version of the PCS in March 2019 that will provide individuals potential entitlement to Title II benefits only on their own SSNs. In this initial release, we will limit the respondents for the PCS to first party adults or legally incompetent adults with a legal guardian who:
Are age 61 and 8 months or allege being disabled;
Have an SSN;
Do not have an existing record for SSA entitlement (i.e. Title II, Title XVI, Medicare);
Do not have an existing SSA claim (i.e. MCS, MSSICS, iClaim); and
Are not minor children, or adults applying or inquiring on behalf of a minor child.
The March release will go to only eight field offices (VA, CT, MN, OH, CA, DE, DC, and IL) to identify potential defects. We are using the Agile method for creating the PCS and will continue with incremental quarterly releases to enhance PCS’s functionality and respondents (see our Future Plans section below). We plan to release the PCS nationally by the fourth quarter of FY2019.
We do not expect the public reporting burden to change when using the PCS in conjunction with taking a claim.
Revisions to the Collection Instruments – SSA-8001-BK (PCS Screens):
Change #1: Upon OMB’s approval, the Preliminary Claims System (PCS) will serve as another modality for collecting some of the SSI application questions, effective March 2019.
Justification #1: Using the PCS as another modality for collecting application questions prevents redundancy in asking respondents’ questions that are common to our SSI application and the pre-claim interview.
Change #2: We will require technicians to use PCS to identify Title II potential entitlements prior to taking an SSI claim.
Justification #2: Adding PCS to the SSI claims process will ensure the technicians identify which Title II benefit(s) an individual must file for to meet the SSI eligibility requirement of filing for other benefits.
Change #3: We are increasing the developmental costs for this collection by $1,845,455 to account for the creation and implementation of the PCS for the SSI application.
Justification #3: The overall estimated developmental cost for creating the PCS is $20.3 million. This estimate provides for the multi-year effort, and accounts for the database and computational services work, as well as the overhead costs, based on what we know today. Since the PCS serves as a collection tool for eight Title II applications; two Title XVI applications; and iClaim, we are applying portions of the total developmental cost among the eleven applications.
Change #4: The Office of Privacy and Discloser created a new Privacy Act Statement for technicians to use when conducting a pre-claim interview with the PCS.
Justification #4: 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 form.
We will implement these revisions upon OMB’s approval for this information collection request. We do not expect any of these revisions to affect the current reporting burden.
Future Revisions to the Collection Instrument
We intend to enhance PCS’s functionality so that it will identify an individual’s potential entitlement for SSI, and calculate payment amount with the June 2019 release. As we will use the Agile method for these revisions, we will submit subsequent Change Requests to show our revisions once the PCS screens are available.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Title of Information Collection and Form Number(s) |
| Author | Naomi |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |