View Information Collection Request (ICR) Package
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View Supporting Statement and Other Documents
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:
0960-0323
ICR Reference No:
202104-0960-012
Status:
Active
Previous ICR Reference No:
201802-0960-003
Agency/Subagency:
SSA
Agency Tracking No:
Title:
Third Party Liability Information Statement
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
08/12/2024
Retrieve Notice of Action (NOA)
Date Received in OIRA:
09/10/2021
Terms of Clearance:
The agency made minor modifications to the Supporting Statement to clarify the operation of the information collection. The agency also removed a wet signature requirement on the form consistent with Sec. 4 (k)(iii) and (iv) of E.O. 14058.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
08/31/2027
36 Months From Approved
08/31/2024
Responses
35,457
0
49,821
Time Burden (Hours)
15,886
0
4,152
Cost Burden (Dollars)
0
0
0
Abstract:
To reduce Medicaid costs, Medicaid state agencies identify third party insurers liable for medical care or services for Medicaid beneficiaries. Applications for and redeterminations of SSI eligibility in jurisdictions with such agreements are applications and redeterminations of Medicaid eligibility. Under these agreements, SSA obtains third party liability information using Form SSA-8019, and provides that information to the Medicaid state agencies. The Medicaid state agencies use the information to bill third parties 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.
Authorizing Statute(s):
US Code:
42 USC 1383c
Name of Law: Social Security Act
US Code:
42 USC 1396a
Name of Law: Social Security Act
Citations for New Statutory Requirements:
None
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:
86 FR 35371
07/02/2021
30-day Notice:
Federal Register Citation:
Citation Date:
86 FR 49403
09/02/2021
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
Third Party Liability Information Statement - Paper SSA-8019
SSA-8019
Third Party Liability Information Statement
Third Party Liability Information Statement - SSI Claims System
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
35,457
49,821
0
0
-14,364
0
Annual Time Burden (Hours)
15,886
4,152
0
0
11,734
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:
When we last cleared this IC in 2018, the burden was 4,152 hours. However, we are currently reporting a burden of 3,546 hours. This change stems from a decrease in the number of responses from 49,621 to 35,457. In addition, we increased the completion time per response from 5 to 6 minutes, as we reassessed our burden estimate and found that current MI data supports an increase by one minute. These figures represent current Management Information data. * Note: The total burden reflected in ROCIS is 15,886, while the burden cited in #12 of the Supporting Statement is 3,546. This discrepancy is because the ROCIS burden reflects field office waiting time in addition to the overall burden per response. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.
Annual Cost to Federal Government:
$139,250
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Yes
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
Yes
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
No
Agency Contact:
Faye Lipsky 410 965-8783 faye.lipsky@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:
09/10/2021
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