Medicaid Use Report

Forms and Documents

Document Name	Status
Supporting Statement - 0267.docx Supporting Statement A	2020-10-19

IC Document Collections

IC ID	Document Title	Status
9170	Medicaid Use Report Other-Internal Screens	Modified

ICR Details

OMB Control No: 0960-0267	ICR Reference No: 202008-0960-007
Status: Received in OIRA	Previous ICR Reference No: 201707-0960-004
Agency/Subagency: SSA	Agency Tracking No:
Title: Medicaid Use Report
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/19/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2021
Responses	60,000	60,000
Time Burden (Hours)	3,000	3,000
Cost Burden (Dollars)	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 42 USC 1382h Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 45723	07/29/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 63630	10/08/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicaid Use Report

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ICR Summary of Burden

	Total Request	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	60,000	60,000	0	0	0	0
Annual Time Burden (Hours)	3,000	3,000	0	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:

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Annual Cost to Federal Government: $1,444,900

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

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Common Form ICR:  No

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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: 10/19/2020

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