OMB control number

State Supplementation Provisions: Agreements; Payments

OMB 0960-0240 · SSA.

OMB 0960-0240

SSA collects the pass-along increase information from each state agency that: (1) administers a state supplementary program; and (2) has agreed to comply with the provisions of the Act. The information we request allows SSA to determine each state's compliance or noncompliance with the pass-along requirements of the Act. Federal participation in the state's Medicaid program, under Title XIX of the Act, is dependent upon SSA’s determination of a state's compliance. States report supplementary payment information annually (for states complying by the maintenance of payment levels method). SSA may ask them to report up to four times per year (for states complying by the total-expenditures method). This collection asks respondents (i.e., states) to confirm their compliance with the pass along requirements, and to provide any changes to their optional supplementary payment rates. The respondents are state agencies administering supplementary income payment programs.

The latest form for State Supplementation Provisions: Agreements; Payments expires 2027-11-30 and can be found here.

Latest Forms, Documents, and Supporting Material
All Historical Document Collections
Revision of a currently approved collection 2021-11-24
Approved without change
Revision of a currently approved collection 2018-10-08
Approved without change
Revision of a currently approved collection 2015-09-01
Approved without change
Extension without change of a currently approved collection 2012-12-03
Approved without change
Extension without change of a currently approved collection 2009-10-29
Approved without change
Extension without change of a currently approved collection 2006-11-01
Approved without change
Extension without change of a currently approved collection 2003-11-07
Approved without change
Extension without change of a currently approved collection 2000-09-12
Approved without change
Extension without change of a currently approved collection 1997-09-25
Approved without change
Extension without change of a currently approved collection 1994-08-17
Approved without change
Extension without change of a currently approved collection 1991-07-01
Approved with change
No material or nonsubstantive change to a currently approved collection 1989-06-28
Approved without change
Extension without change of a currently approved collection 1988-06-30
Approved without change
Extension without change of a currently approved collection 1985-07-29
Approved without change
Extension without change of a currently approved collection 1982-09-29
Approved without change
New collection (Request for a new OMB Control Number) 1981-03-23
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Federal Enterprise Architecture: Income Security - General Retirement and Disability