View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0960-0269
ICR Reference No:
200610-0960-001
Status:
Historical Active
Previous ICR Reference No:
200411-0960-006
Agency/Subagency:
SSA
Agency Tracking No:
Title:
Request for Hearing By Administrative Law Judge, 20 CFR 404.929, 404.933, 416.1429, 404.1433, 405.722, 418.1350
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Emergency
Approval Requested By:
11/02/2006
OIRA Conclusion Action:
Approved with change
Conclusion Date:
11/22/2006
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/19/2006
Terms of Clearance:
This emergency ICR is approved on the following conditions: 1) SSA will immediately begin work to update the form so that it is applicable to HHS ALJs and will print these new forms after the full ICR has been approved; 2)within 30 days after approval is granted, SSA will publish a 60-day FR notice and begin the process for a full ICR; 3)SSA will keep track of burden and update as necessary
Inventory as of this Action
Requested
Previously Approved
Expiration Date
05/31/2007
6 Months From Approved
01/31/2008
Responses
669,469
0
667,236
Time Burden (Hours)
111,578
0
111,206
Cost Burden (Dollars)
0
0
0
Abstract:
SSA uses form HA-501 to document when applicants for Social Security benefits have their claims denied and want to request an administrative hearing to appeal SSAs decision. The scope of this form is now being expanded to include people who wish to appeal the decision that has been made regarding their obligation to pay a new Income-Related Monthly Adjustment Amount (IRMAA) for Medicare Part B, as per the requirements of the Medicare Modernization Act of 2003. Although this information will be collected by SSA, the actual hearings will take place before administrative law judges (ALJ) who are employed by the Department of Health and Human Services (HHS). The current respondents include applicants for various Social Security benefits programs who want to request a hearing where they can appeal their denial; the new additional respondents are Medicare Part B recipients whom SSA has determined will have to pay the new Medicare Part B IRMAA and who wish to appeal this decision at a hearing before an HHS ALJ.
Emergency Justfication:
SSA is re-clearing this form to use it for Medicare Part B appeals. As per Rachel Potter's instructions, we are requesting re-clearance on an emergency basis because of time constraints. Please see attached letter which gives a detailed justification for this request.
Authorizing Statute(s):
PL:
Pub.L. 108 - 173 1350
Name of Law: Medicare Modernization Act of 2003
Citations for New Statutory Requirements:
PL: Pub.L. 108 - 173 1350 Name of Law: Medicare Modernization Act of 2003
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
71 FR 61820
10/19/2006
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Request for Hearing By Administrative Law Judge, 20 CFR 404.933, 20 CFR 405.722
HA-501
Request for Hearing by Administrative Law Judge
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
669,469
667,236
2,233
0
0
0
Annual Time Burden (Hours)
111,578
111,206
372
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Increase in burden is due to the additional number of respondents who will now use this form for Medicare Part B appeals.
Annual Cost to Federal Government:
$1,050,000
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
Uncollected
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
Uncollected
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
Uncollected
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Elizabeth Davidson 411-965-0454 liz.davidson@ssa.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
10/19/2006
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