supporting statement-Part A

Supporting Statement for the Request for Retirement Benefit Information

A. Background

This form is used to obtain information regarding whether a beneficiary currently buying Medicare Part A coverage, is receiving retirement payments based on State or local government employment, how long the claimant worked for the State or local government employer, and whether the former employer or pension plan is subsidizing the individual’s Part A premium.

B. Justification

1. Need and Legal Basis

§1818 ((d)(5) of the Social Security Act (the Act) provides that former State and local government employees who are age 65 or older, have been entitled to Premium Part A for at least 7 years, and did not have the premium paid for by a State, a political subdivision of a State, or an agency or instrumentality of one or more States or political subdivisions thereof, may have the Part A premium reduced to zero. These individuals must also have 10 years of employment with the State or local government employer or a combination of 10 years of employment with a State or local government employer and a non-government employer.

This collection form is an essential part of the process of determining whether an individual qualifies for the premium reduction.

2. Information Users

The Social Security Administration (SSA) will use this information to help determine whether a beneficiary meets the requirements for reduction of the Part A premium.

3. Use of Information Technology

The collection of this information does not involve the use of information technology.

4. Duplication of Efforts

This information does not duplicate any other effort.

5. Small Businesses

Small businesses are not affected by this collection.

6. Less Frequent Collection

This information will be collected on an ‘as needed’ basis. If it were to be collected less frequently, beneficiaries would be adversely affected.

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 November 14, 2008 and a 30-day notice was published on February 13, 2009. No comments were received.

The Centers for Medicare & Medicaid Services (CMS) consulted with SSA’s Regional Offices, Office of Public Service Operations Support, and the Office of Telephone Services to obtain their input regarding the information being requested.

9. Payment/Gift To Respondents

There were no payments or gifts provided to respondents.

10. Confidentiality

This collection will be used solely by SSA for the express purpose of determining a beneficiary’s eligibility for the reduction of the Medicare Part A premium.

11. Sensitive Questions

There are no sensitive questions.

12. Burden Estimate (Hours & Wages)

$3750.00 ($10 per hour multiplied by 375 hours). The approximate number of respondents is 1500.

13. Capital Costs

0

14. Cost to Federal Government

This information is provided by retirement/pension plans. There is no cost to the Federal Government.

15. Changes to Burden

None

16. Publication/Tabulation Dates

None

17. Expiration Date

CMS would like an exemption from displaying an expiration date as this form is used on a continuing basis. To include an expiration date would result in having to discard a potentially large number of forms.

18. Certification Statement

There are no exceptions to the certification statement.

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