CMS-R-297 Supporting Statement

Supporting Statement for the Request For Employment Information Form

1. Background

We are requesting an extension of a currently approved collection under 0938-0787.

This form is used by the Social Security Administration to obtain information from employers regarding whether a Medicare beneficiary’s coverage under a group health plan is based on current employment status.

B. Justification

1. Need and Legal Basis: Section 1837(i) of the Social Security Act (the Act) provides for a special enrollment period for individuals who delay enrolling in Medicare Part B because they are covered by a group health plan based on their own or a spouse’s current employment status. When these individuals apply for Medicare Part B, they must provide proof that the group health plan coverage is (or was) based on current employment status.

2. Information Users: The Social Security Administration uses this information to determine whether an individual meets the requirements for a special enrollment period and/or premium surcharge reduction.

3. Improved Information Technology: The collection of this information does not involve the use of information technology.

4. Duplication of Similar Information: The collection of this information does not duplicate any other effort.

5. Small Businesses: Small businesses are not affected by the collection of this information.

6. Less Frequent Collection: This information is collected only as needed. Less frequent collection would adversely affect beneficiaries eligible for a special enrollment period or premium surcharge reduction since they are only allowed to enroll if the employer verifies group health plan coverage based on current employment status.

7. Special Circumstances: There are no special circumstances involved with the collection of this information.

8. Federal Register Notice/Outside Consultation: A 60-day Federal Register Notice was published on April 20, 2007, attached.

CMS consulted with SSA’s Regional Offices, Program Services Centers, Office of Public Service Operations Support, and the Office of Telephone Services to obtain their input regarding the information collection.

9. Payment/Gift To Respondent: There were no payments or gifts to respondents.

10. Confidentiality: The information collected is used only by SSA for the purpose of determining a beneficiary’s eligibility for a special enrollment period and/or premium surcharge reduction.

11. Sensitive Questions: There are no sensitive questions.

12. Burden Estimate (Total Hours & Wages): $12500 ($10 per hour multiplied by 1250 hours). The approximate number of respondents is 5000. We estimate it will take 15 minutes to complete the form. (5000 x 15 /60 = 1250 hours)

13. Capital Costs (Maintenance of Capital Costs):

There are no capital costs.

14. Cost to Federal Government: This information is provided by employers. There is no cost to the Federal Government.

15. Program/Burden Changes:

There are no program changes.

16. Publication and Tabulation Dates: None

17. Expiration Date: CMS would like to display the expiration date.

18. Certification Statement: There are no exceptions to the certification statement.

C. Collection of Information Employing Statistical Methods: This information collection does not employ any statistical methods.

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