3220-0086

OMB NO. 3220-0086

Justification

Application for Reimbursement for Hospital Insurance Services in Canada

RRB Form AA-104

1. Circumstances of information collection - Under section 7(d) of the Railroad Retirement Act (RRA), the Railroad Retirement Board (RRB) administers the Medicare program for persons covered by the railroad retirement system. Payments are provided under section 7(d)(4) of the RRA, for medical services furnished in Canada to the same extent as for those furnished in the United States. However, payments for the services furnished in Canada are made from the Railroad Retirement Account rather than from the Federal Hospital Insurance Trust Fund, with the payments limited to the amount by which insurance benefits under Medicare exceed the amount payable under Canadian Provincial plans.

2. Purposes of collecting/consequences of not collecting the information - Form AA-104, Application for Canadian Hospital Benefits Under Medicare - Part A, is provided by the RRB for use in claiming payment for covered hospital services received in Canada. In addition, the form obtains information needed by the RRB to determine the eligibility of the applicant, and the amount of any reimbursement due.

The self-administered form, along with pamphlet RB-104, Health Insurance for Railroad Retirement Beneficiaries in Canada, is furnished to Canadian residents when they receive their health insurance identification cards. Other claimants desiring to claim benefits for covered Canadian hospital services are supplied with the form on request.

Forms AA-104 found by the RRB to be valid, i.e., entitlement for the benefits exist, are forwarded to Western Benefits Administration, the RRB's Canadian agent, to verify the information and obtain the amounts payable for the Canadian hospital services under the applicable Canadian provincial plan. After the information is obtained, the claims are processed and payment is issued by the RRB to the claimants. Enclosed with each payment is a Form AA-104 for use in filing a subsequent claim.

The RRB proposes the following non-burden impacting editorial and cosmetic changes to Form AA-104.

• Renumber Current Item 5a to proposed Item 5

• Split form into Sections 1 and 2. If proposed Item 5 is answered “Yes” the applicant goes to Section 1; if Item 5 is answered “No,” the applicant goes to Section 2.

Section 1 – Services provided before period of this claim (current Item 5b).

• Current Item 5b has two separate items (1) the Name and Address of the Hospital or Home and (2) the type of service and the admitted and discharged dates. We propose to split them into:

• Proposed Item 6a, type of service and admitted and discharged dates

• Proposed Item 6b, the Name and Address of the Hospital or Home. For clarity, we also propose to reformat Item 6b into an instruction and provide more room for a response. Included in the address is a request for the Province, to make it consistent with current Item 13.

Section 2 – Services provided before period of this claim (current Item 5b).

• For fluidity, we propose to reformat Current Item 6, Name and Address of Hospital and Current Item 7, Type of Service with the admitted and discharge dates, to match the format of proposed Items 6a and 6b in Section 1.

• Reformat current Item 6 to proposed Item 7b. Also, since the address could be the same address that was previously provided in Item 6b, we propose to add the applicant should only complete Item 7b if the address is different. Otherwise they can now enter an “X” in a box to indicate the address was already furnished in Item 6b.

• Renumber current Item 7 to proposed Item 7a.

• Update the Paperwork Reduction Act language.

To our knowledge, no other agency obtains information similar to that being obtained by Form AA-104.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction – None planned. Not cost effective due to low volume.

4. Efforts to identify duplication - This information collection does not duplicate any other information collection.

5. Small business respondents - N.A.

6. Consequences of less frequent collection - Not applicable since the information is solicited only once.

7. Special Circumstances - N.A.

8. Public Comments/Consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding the information collection. The notice to the public was published on pages 10075 of the February 25, 2008 Federal Register. No requests for further information or comments were received.

9. Payments or gifts to respondents – None.

10. Confidentiality - Privacy Act System of Records, RRB-20, Health Insurance and Medicare Medical Insurance Enrollment and Premium Payment System (Medicare) - RRB.

11. Sensitive questions - There are no questions of a sensitive nature.

12. Estimate of respondent burden -The current and proposed burden for the collection is as follows:

Current Burden

Form #	Annual Responses	Time (Min)	Burden (Hrs)
AA-104	50	10	8
Total	50		8

Proposed Burden

Form #	Annual Responses	Time (Min)	Burden (Hrs)
AA-104	35	10	6
Total	35		6

Responses Hours

Total Burden Change -15 -2

Adjustment -15 -2

13. Estimate of annual cost burden to respondents or recordkeepers - N.A.

14. Estimate of cost to Federal government - N.A.

15. Explanation for change in burden - N.A.

16. Time schedule for data collection and publication - The results of this collection will not be published.

17. Request to not display OMB expiration date - The AA-104 is seldom revised. Given the costs associated with redrafting, reprinting and distributing the form in order to keep the appropriate OMB expiration date in place, the RRB requests authorization to not display the expiration date on the form.

18. Exceptions to Certification Statement - None

4