Supporting Statement - Part A

Supporting Statement - Part A.doc

Request for Employment Information

OMB: 0938-0787

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Supporting Statement – Part A


A. Background


We are requesting an extension of a currently approved collection under 0938-0787. This form is used by the Social Security Administration (SSA) 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. Use of Information Technology


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


4. Duplication of Efforts


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/Outside Consultation


A 60-day Federal Register notice published on April 19, 2010. No comments were received.


9. Payments/Gifts to Respondents


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 Estimates (Hours & Wages)


$12,500 ($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 16/60 = 1250 hours)


13. Capital Costs


There are no capital costs.


14. Cost to Federal Government


$10,500. The approximate number on respondents is 5000. We estimate that it takes an SSA field office GS-9 staff 5 minutes to manage/oversee the use of the form. The 2010 GS-9 hourly rate of $25.22 x .0833 hours 95 minutes) x 5000 (number of forms) = $10, 500.


15. Changes to Burden


There are no program changes.


16. Publication/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.



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File Typeapplication/msword
AuthorCMS
Last Modified ByCMS
File Modified2010-07-08
File Created2010-03-08

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