RL-380-F (proposed Report of Medicaid State Office on Beneficiary's Buy-In

Form Approved
OMB NO.3220-0185

RRB Claim Number

Send reply to:

Medicare Claim Number
U.S. RAILROAD RETIREMENT BOARD
Part A Effective Date

Part B Effective Date

Beneficiary's Own Social Security Number
Beneficiary's DOB

Sex:
Male [7 Female [7
Social Security Claim Number

Report of Problem:

[7 Buy-in Accretion Alleged

Medicaid Number

[7 Buy-in Deletion Alleged

Beneficiary's Name

[7 Other:

Beneficiary's Address:

Signature of RRB Employee

Title

Telephone Number

Date

Information from State Records or Action Being Taken by State
Read the important notice on the next page.

To be completed by State Representative

1. [7 State has been paying Medicare premium since
(MonthNear)
2. [7 State paid Medicare premium from

through
(MonthNear)

3. [7 Beneficiary died
(MonthNear)

(MonthNear)

Form Approved
OMB NO.3220-0185

4.

Claim number under which state paid premium (if different from RRB Medicare claim number)

5.

State will submit a buy-in accretion effective
exchange with CMS.
(MonthNear)

6.

State will submit a buy-in deletion effective
exchange with CMS.
(MonthNear)

in the

data
(MonthNear)

in the

data
(MonthNear)

7.

Buy-in problem case on this beneficiary was submitted to CMS on
. Allow
days for resolution.
(MonthNear)

8.

Beneficiary never eligible for buy-in.

9.

State has no record of this beneficiary. Beneficiary should contact the following office and file
a Medicaid application.

10.

RRB inquiry has been referred to the office listed in item 9 above.

11.

Other:

Signature of State Representative

Title

Printed Name

Telephone Number

Date

Return this form to the Railroad Retirement Board at the address shown on the first page.
Paperwork Reduction Act Notice

This notice is given under the Paperwork Reduction Act of 1995. Under Section 7(d) of the Railroad
Retirement Act (RRA), the Railroad Retirement Board (RRB) is authorized to collect the information
requested on this form. The information is needed by the RRB to determine the eligibility of an individual
receiving benefits under the RRA for the payment of his or her Medicare medical insurance (Part B)
premiums by the State. The information is also used by the RRB to determine if we should stop premium
deductions for Medicare medical insurance from the benefits paid to the individual. Your obligation to
provide us with this information is required under the law.
We estimate this form takes an average of 10 minutes to complete, including the time for getting the needed
data and reviewing the completed form. Federal agencies may not conduct or sponsor, and respondents are
not required to respond to, a collection of information unless it displays a valid OlVlB number. If you wish,
send comments regarding the accuracy of our estimate or any other aspect of this form, including
suggestions for reducing completion time, to the Chief of Information Resources Management, Railroad
Retirement Board, 844 North Rush Street, Chicago, Illinois 60611-2092.