Supporting Statement - Part A

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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