REPORT OF MEDICAID STATE OFFICE ON BENEFICIARY'S BUY-IN STATUS

ICR 199207-3220-001

OMB: 3220-0185

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
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ICR Details
3220-0185 199207-3220-001
Historical Active
RRB
REPORT OF MEDICAID STATE OFFICE ON BENEFICIARY'S BUY-IN STATUS
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 09/11/1992
Retrieve Notice of Action (NOA) 07/10/1992
  Inventory as of this Action Requested Previously Approved
09/30/1995 09/30/1995
600 0 0
100 0 0
0 0 0

UNDER THE RRA, THE RAILROAD RETIREMENT BOARD ADMINISTERS THE MEDICARE PROGRAM FOR PERSONS COVERED BY THE RAILROAD RETIREMENT SYSTEM. THE COLLECTION OBTAINS INFORMATION NEEDED TO DETERMINE IF CERTAIN RAILROAD BENEFICIARIES ARE ENTITLED TO RECEIVE SUPPLEMENTARY MEDICAL INSURANCE PROGRAM COVERAGE UNDER A STATE BUY-IN AGREEMENT IN STATES IN WHICH THE

None
None


No

1
IC Title Form No. Form Name
REPORT OF MEDICAID STATE OFFICE ON BENEFICIARY'S BUY-IN STATUS RL-380-F

  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 600 0 0 600 0 0
Annual Time Burden (Hours) 100 0 0 100 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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.
07/10/1992


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