OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Third Party Liability Information Statement

ICR 201504-0960-001 · OMB 0960-0323 · Historical Active

Forms and Documents
Document
Name
Status
Form
 Modified
Supplementary Document
2015-07-08
Supporting Statement A
2015-08-24
IC Document Collections
IC ID
Document
Title
Status
43701 Modified
189371 Modified
ICR Details
0960-0323 201504-0960-001
Historical Active 201201-0960-008
SSA
Third Party Liability Information Statement
Revision of a currently approved collection   No
Regular
Approved with change 08/24/2015
Retrieve Notice of Action (NOA) 07/08/2015
This collection is approved based on the revised materials provided by the Agency.
  Inventory as of this Action Requested Previously Approved
08/31/2018 36 Months From Approved 10/31/2015
51,581 0 67,034
4,299 0 5,586
0 0 0
Medicaid state agencies must identify third party insurers liable for medical care or services for Medicaid beneficiaries; this reduces Medicaid costs. Regulations at 42 CFR 433.136–433.139 require Medicaid state agencies to obtain this information on Medicaid applications and redeterminations as a condition of Medicaid eligibility. States may enter into agreements with the Commissioner of Social Security to make Medicaid eligibility determinations for aged, blind, and disabled beneficiaries in those states. Applications for and redeterminations of Supplemental Security Income (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.
US Code: 42 USC 1396a Name of Law: Social Security Act
   US Code: 42 USC 1383c Name of Law: Social Security Act
  
None
Not associated with rulemaking
  80 FR 24307 04/30/2015
80 FR 37708 07/01/2015
No
  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 51,581 67,034 0 0 -15,453 0
Annual Time Burden (Hours) 4,299 5,586 0 0 -1,287 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
There has been a decrease in the burden hours. The change in hours reflects normal workload variations, and a decrease in the number of users. Based on the nature and purpose of the form there have been fewer situations where the form has been necessary.
$531,694
No
No
No
No
No
Uncollected
Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
07/08/2015