Justification
Introduction/Authoring Laws and Regulations
The Federal Employee Health Benefits (FEHB) Program allows dependent children of Federal employees to continue receiving health care benefits as covered family members until age 26. At age 26, children’s FEHB coverage terminates. However, as stated in Section 5 CFR 890.302(d) of the Code of Federal Regulations, children ages 26 and older can continue to receive health benefits under the FEHB Program if they are incapable of self-support due to a disability. FEHB rules require a physician to verify the disability of Federal employees’ plans. The physician must verify the adult child has a disability that meets the following criteria: (1) pre-dates the child’s 26th birthday; (2) is very serious; and (3) we expect to last at least one year. The Social Security Administration (SSA) uses the information to determine adult children’s (age 26 and above) eligibility for coverage under a parent’s FEHB plan.
Description of Collection
Physicians use Form SSA-604, the Certificate of Incapacity, to document and certify the disability of children ages 26 and over, whose parents are SSA employees. SSA uses the information provided to determine the eligibility for these children, ages 26 and over, for coverage under a parent’s FEHB plan. The respondents are physicians of SSA employees’ children, ages 26 or over who are seeking to retain health benefits under their parent’s FEHB coverage.
Use of Information Technology to Collect the Information
SSA created a fillable PDF of Form SSA-604 which is available on our website for respondents to download, complete, print, and submit to SSA. We cannot accept emailed responses as email is an insecure method to transmit the data, and HIPAA law requires medical information to be transmitted via secure means. Due to the low volume of respondents, this form is not a good candidate for electronic implementation.
Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it preclude duplication. SSA does not use another collection instrument to obtain similar data.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
Consequence of Not Collecting Information or Collecting it Less Frequently
If we did not use Form SSA-604, SSA employees with children ages 26 and over who qualify for the FEHB program because of their disabilities would have no means of applying to retain their health coverage. Because the physicians only complete the form once, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.
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.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on May 2, 2019 at, at 84 FR 18913, and we received no public comments. The 30-day FRN published on July 18, 2019 at 84 FR 34469. If we receive any comments in response to this Notice, we will forward them to OMB. We did not consult with the public in the revision or maintenance of this form.
Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
Assurances of Confidentiality
SSA protects and holds confidential the information it collects 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.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
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-604 |
50 |
1 |
45 |
38 |
The total burden for this ICR is 38 hours. We based this figure on current management information data, and it represents burden hours. We did not calculate a separate cost burden.
Annual Cost to the Respondents (Other)
This collection does not impose a known cost burden on the respondents.
Annual Cost To Federal Government
The annual cost to the Federal Government is approximately $6,730. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; and (2) SSA employee (e.g., field office, 800 number, DDS staff) information collection and processing time.
Program Changes or Adjustments to the Information Collection Request
There are no changes to the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
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.
Exceptions 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).
Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
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| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |