Supporting Statement for Medicaid Use Report
20 CFR 416.268
OMB 0960-0267
Introduction/Authoring Laws and Regulations
Section 1619(b) of the Social Security Act (Act) and 20 CFR 416.268 of the Code of Federal Regulations require the Social Security Administration (SSA) to determine eligibility for: (1) special Supplemental Security Income (SSI) payments and (2) special SSI eligibility status for a person who works despite a disabling condition. It also provides that to qualify for special SSI eligibility status, individuals must establish that termination of eligibility for SSI payments would seriously inhibit their ability to continue employment. This information collection request (ICR) is for the public reporting burdens contained in 20 CFR 416.268.
Description of Collection
During a personal or telephone interview with the SSI recipient, an SSA employee asks the following questions:
Have you used any medical care or services in the past 12 months that were paid for by Medicaid (or Medi-Cal, etc.)?
Do you expect to receive any medical care or services in the next 12 months that will be paid for by Medicaid (or Medi-Cal, etc.)?
Without Medicaid (Medi-Cal, etc.), would you be unable to pay your medical bills if you become ill or injured in the next 12 months?
We use this information to determine if an SSI recipient whose payments have stopped based on earnings, is entitled to special SSI payments and, consequently, to Medicaid benefits under section 1619 (b) of the Act. The respondents are SSI recipients for whom SSA has stopped payments based on earnings.
Use of Information Technology to Collect the Information
SSA has no specific format for this collection, and, currently, we collect it through a personal interview for 98 percent of all respondents. During the personal interview, SSA personnel record responses using one of the Remarks sections of the SSI Claims System. For those times when the SSI Claims System is down, we use Form SSA-795, Statement of Claimant or Other Person (OMB No. 0960-0795) to record this information, and SSA personnel key the information into the SSI Claims System later. We expect that happens about 2 percent of the time. Under this ICR, we account for the burden for the SSI Claims System respondents only, as we account for those who use the SSA-795 under OMB No. 0960-0795. This information collection does not currently allow for electronic submission or electronic disclosure under GPEA as it has been conveyed to us by OIRA.
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 collect similar data.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
Consequences of Not Collecting Information or Collecting it Less Frequently If SSA did not collect this information, we would be unable to determine an individual’s coverage under section 1619(b) of the Act, which could result in termination of their Medicaid assistance. We collect this information on an as needed basis; therefore, we cannot collect it less frequently. There are no technical or legal obstacles that would prevent burden reduction.
Special Circumstances
There are no special circumstances that would cause us 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 July 29, 2020, at
85 FR 45723, and we received no public comments. The 30-day FRN published on October 8, 2020 at 85 FR 63630. 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 maintenance of this collection.
Payment or Gifts to Respondents
We provide no payment or gifts to the respondents.
Assurances of Confidentiality
We protect and hold confidential the information we request 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) |
Average Theoretical Hourly Cost Amount (dollars)* |
Average Wait Time in Field Office (minutes) ** |
Total Annual Opportunity Cost (dollars)*** |
20 CFR 416.268 SSI Claims System |
60,000 |
1 |
3 |
3,000 |
$10.73* |
24** |
$289,710*** |
* We based this figure on average DI payments based on SSA's current FY 2020 data (https://www.ssa.gov/legislation/2020Fact%20Sheet.pdf).
** We based this figure on the average FY 2020 wait times for field offices, based on SSA’s current management information data.
*** This figure does not represent actual costs that SSA is imposing on recipients of Social Security payments to complete this application; rather, these are theoretical opportunity costs for the additional time respondents.
In addition, OMB’s Office of Information and Regulatory Affairs is requiring SSA to use a rough estimate of a 30-minute, one-way, drive time in our calculations of the time burden for this collection. OIRA based their estimation on a spatial analysis of SSA’s current field office locations and the location of the average population centers based on census tract information, which likely represents a 13.97-mile driving distance for one-way travel. We depict this on the chart below:
Total Number of Respondents Who Visit a Field Office |
Frequency of Response |
Average One-Way Travel Time to a Field Office (minutes) |
Estimated Total Travel Time to a Field Office (hours) |
Total Annual Opportunity Cost for Travel Time (dollars)**** |
60,000 |
1 |
30 |
30,000 |
$321,900 |
****We based this dollar amount on the Average Theoretical Hourly Cost Amount in dollars shown on the burden chart above.
Per OIRA, we include this travel time burden estimate under the 5 CFR 1320.8(a)(4), which requires us to provide “time, effort, or financial resources expended by persons [for]…transmitting, or otherwise disclosing the information,” as well as 5 CFR 1320.8(b)(3)(iii) which requires us to estimate “the average burden collection…to the extent practicable.” SSA notes that we do not obtain or maintain any data on travel times to a field office, nor do we have any data, which shows that the average respondent drives to a field office, rather than using any other mode of transport. SSA also acknowledges that respondents’ mode of travel and, therefore, travel times vary widely dependent on region, mode of travel, and actual proximity to a field office.
NOTE: We included the total opportunity cost estimate from this chart in our calculations when showing the total time and opportunity cost estimates in the paragraph below.
We base our burden estimates on current management information data, which includes data from actual interviews, as well as from years of conducting this information collection. Per our management information data, we believe that
3 minutes accurately shows the average burden per response for reading the instructions, gathering the facts, and answering the questions. Based on our current management information data, the current burden information we provided is accurate. The total burden for this collection instrument is 3,000 burden hours (reflecting SSA management information data), which results in an associated theoretical (not actual) opportunity cost financial burden of $611,610. SSA does not charge respondents to complete our applications.
Cost to Respondents
There is no known cost burden to the respondents.
Annual Cost to the Federal Government
The annual cost to the Federal Government is approximately $1,444,900. This estimate accounts for costs from the following areas:
Description of Cost Factor |
Methodology for Estimating Cost |
Cost in Dollars* |
Designing and Printing the Form |
Design Cost + Printing Cost |
$0 |
Distributing, Shipping, and Material Costs for the Form |
Distribution + Shipping + Material Cost |
$0 |
SSA Employee (e.g., field office, 800 number, DDS staff) Information Collection and Processing Time |
GS-9 employee x # of responses x processing time |
$76,777 |
Full-Time Equivalent Costs |
Out of pocket costs + Other expenses for providing this service |
$0 |
Systems Development, Updating, and Maintenance |
GS-9 employee x man hours for development, updating, maintenance |
$1,368,123 |
Quantifiable IT Costs |
Any additional IT costs |
$0 |
Total |
|
$1,444.900 |
* We have inserted a $0 amount for cost factors that do not apply to this collection.
SSA is unable to break down the costs to the Federal government further than we already have. It is difficult for us to break down the cost for processing a single information collection, as field office and State Disability Determination Services staff often help respondents fill out several forms at once, and the time it takes to do so can vary greatly per respondent. As well, because so many employees have a hand in each aspect of our collections, we use an estimated average hourly wage, based on the wage of our average field office employee (GS-9) for these calculations. However, we have calculated these costs as accurately as possible based on the information we collect for creating, updating, and maintaining these information collections.
Program Changes or Adjustments to the Information Collection
There are no changes in the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Expiration Date
SSA is not requesting an exception to the requirement to display an expiration date.
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).
SSA does not use statistical methods for this information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement for Medicaid Use Report |
| Author | CHARTSON |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |