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 to a claimant seeking reimbursement for covered hospital services received in Canada. 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 and pamphlet RB-104, Medicare for Railroad Retirement Beneficiaries in Canada, are furnished to Canadian residents when they receive their health insurance identification cards. Other claimants desiring to claim reimbursement for covered Canadian hospital services are supplied with the form on request.

When a claim is found by the RRB to be valid (i.e., entitlement for the benefits exists), Form AA-104 is forwarded to Western Benefits Administration, the RRB's Canadian agent, to verify the information and obtain the amounts payable under the applicable Canadian provincial plan. After the information is obtained, the claim is processed and payment is issued by the RRB to the claimant. 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 changes to Form AA-104:

• Insert “(HI)” after “Health Insurance” in the header above Items 2 through 4.

• Item 3 - Reword “Claim Number with Prefix” to “HI Claim Number.”

• Item 7b - Replace reference to “Item 7b” with “this item” and correct referenced “Item 5c” to “Item 6b.”

• Minor cosmetic changes.

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 29282 and 29283 of the May 20, 2011, 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. http://www.rrb.gov/pdf/PIA/PIA-BPO.pdf

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

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

Current Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
AA-104	35	10	6
Total	35		6

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

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