Authorization for SSA to Disclose Tax Information for Your Appeal of Your Medicare Part B Income-Related Monthly Adjustment Premium Amount, 20 CFR 418.1350

Forms and Documents

Document Name	Status
Form SSA-54 Authorization for SSA to Disclose Tax Information for Your Appeal of Your Medicare Part B Income-Related Monthly Adjustment Premium Amount Form and Instruction	New
SSA-54 (0960-NEW) supporting statement.doc Supporting Statement A	2007-10-23

IC Document Collections

IC ID	Document Title	Status
182357	Authorization for SSA to Disclose Tax Information for Your Appeal of Your Medicare Part B Income-Related Monthly Adjustment Premium Amount Form and Instruction	New

ICR Details

OMB Control No: 0960-0762	ICR Reference No: 200710-0960-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: SSA	Agency Tracking No:
Title: Authorization for SSA to Disclose Tax Information for Your Appeal of Your Medicare Part B Income-Related Monthly Adjustment Premium Amount, 20 CFR 418.1350
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/13/2007
	Date Received in OIRA: 10/23/2007
Terms of Clearance: SSA agrees that the request for exemption from the requirement to display the expiration date for the OMB control number is not needed, since this form will not be physically printed but will, instead, be posted on SSA's website in PDF format. Prior to posting this form, SSA shall discontinue OMB control #0960-0738, per the supporting statement. For clarification, although SSA will no longer be using IRS form 8821, it is not the IRS form that will be discontinued but, rather, SSA's use of this form through OMB control #0960-0738.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2010	36 Months From Approved
Responses	6,000	0	0
Time Burden (Hours)	1,500	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Medicare Part B beneficiaries who wish to appeal SSA’s reconsideration of their Income-Related Monthly Adjustment Amount (IRMAA) must ensure that the relevant Internal Revenue Service (IRS) income tax data is made available to the Health and Human Services Administrative Law Judge (ALJ) who will consider their appeal. Currently, SSA is using IRS Form-8821 to obtain beneficiary authorization to disclose the IRS beneficiary tax data to the ALJ. With IRS’s concurrence, SSA has developed its own form for this purpose, the SSA-54. The respondents are Medicare Part B recipients who want to appeal SSA’s reconsideration of their IRMAA amount.

---

Authorizing Statute(s): US Code: 42 USC 1395r Name of Law: null
   US Code: 26 USC 6103(a) Name of Law: null
  

Citations for New Statutory Requirements: PL: Pub.L. 108 - 173 811 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:
	72 FR 44211	08/07/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 57629	10/10/2007
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
Authorization for SSA to Disclose Tax Information for Your Appeal of Your Medicare Part B Income-Related Monthly Adjustment Premium Amount	SSA-54	Authorization for SSA to Disclose Tax Information for Your Appeal of Your Medicare Part B Income-Related Monthly Adjustment Premium Amount

---

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	6,000	0	6,000	0	0	0
Annual Time Burden (Hours)	1,500	0	1,500	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: This form is being implemented so the necessary IRS data can be sent to HHS for Medicare Part B redeterminations. The form will replace existing IRS Form 8821, which is currently used for the same purpose.

---

Annual Cost to Federal Government: $0

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

---

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: 10/23/2007

---