OMB NO. 3220-0082
Justification
Medicare
RRB Forms AA-6, AA-7, AA-8 and RL-311-F
1. Circumstances of the collection - Under section 7(d) of the Railroad Retirement Act, the Railroad Retirement Board (RRB) administers the Medicare program for persons covered by the railroad retirement system. The regulations are contained in 42 CFR 406 and 407.
2. Purposes of collecting/consequences of not collecting the information - To obtain information needed to determine whether individuals, who have not yet filed for benefits under the Railroad Retirement Act, are qualified for Medicare under Title XVIII of the Social Security Act, the RRB uses the following forms:
AA-6, Employee Application For Medicare
AA-7, Spouse/Divorced Spouse Application For Medicare
AA-8, Widow/Widower Application For Medicare
When conducting an in-person interview at a field office with applicants for enrollment in Medicare, completion of Forms AA-6, AA-7, and AA-8 is accomplished by means of an on-line computer application called Application Express – APPLE.
In all other cases, the field office mails a printed version of Form AA-6, Form AA-7, or Form AA-8 to the applicant along with transmittal letter Form RL-9, which is used to list and explain any enclosed forms and also to request any necessary proofs for supporting the claim. Informational booklets RB-20, Medicare for Railroad Workers and Their Families and Form RB-3, Furnishing Evidence to Support Your Claim, are also enclosed. The RB-3 describes the types of records that can be used as acceptable evidence when an application is filed and explains where the applicant can obtain these records.
When mailing Form AA-7, the field office also encloses a Form G-346, Employee Certification (OMB 3220-0140), for completion by the employee to certify the spouse's entitlement to benefits. Before release, the field office completes all identifying information on the transmittal letter and forms. The completed form is mailed back to the field office in the pre-addressed envelope provided for that purpose.
The RRB proposes no revisions to Forms AA-6, AA-7 or AA-8.
In order to determine if a qualified railroad retirement beneficiary, who wants to enroll for supplementary medical insurance coverage under Medicare, is entitled to a Special Enrollment Period (SEP) and/or premium surcharge relief because of coverage under a Group Health Plan (GHP), the RRB needs to obtain information regarding the claimant’s GHP coverage, if any. This information includes:
whether the claimant has been covered under a GHP;
the beginning and ending dates of GHP coverage; and
the date the employee’s employment was terminated.
The RRB utilizes Form RL-311-F, Evidence of Coverage Under An Employer Group Health Plan, to obtain the information needed to determine if a qualified railroad retirement beneficiary is entitled to a SEP and/or premium surcharge relief because of coverage under an GHP. Form RL-311-F is released to the employer of the qualified railroad retirement beneficiary to obtain the basic information needed by the RRB to either establish GHP coverage for the applicant who is filing their initial enrollment in Part B coverage, as well as for the individual who wishes to re-enroll for Part B and claim coverage under a GHP or to verify existing coverage for the individual claiming premium surcharge relief based on GHP coverage.
3. Planned use of improved information technology or technical/legal impediments to further burden reduction – None – 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 collected only once from each respondent.
7. Special circumstances - None
8. Public comments/consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding this information collection. The notice to the public was published on page 63960 of the October 14, 2011 Federal Register. No comments or requests for additional information were received from the public.
9. Payments or gifts to respondents - N.A.
10. Confidentiality - Privacy Act System of Records RRB-20, Health Insurance and Supplementary Medical Insurance Enrollment and Premium Payment System (Medicare) - RRB. In accordance with OMB Circular M-03-22, a Privacy Impact Assessment for this information collection was completed and can be found at http://www.rrb.gov/pdf/PIA/PIA-BPO.pdf.
11. Sensitive questions - N.A.
Estimate of respondent burden - The burden for the collection remains unchanged as follows:
Current Burden
Form Number |
Annual Responses |
Time (Minutes) |
Burden (Hours) |
AA-6 |
180 |
8 |
24 |
AA-7 |
50 |
8 |
7 |
AA-8 |
10 |
8 |
1 |
RL-311F |
800 |
10 |
133 |
Total |
1,040 |
|
165 |
13. Estimate of annual cost to respondents or record keepers - N.A.
14. Estimate of cost to Federal Government - N.A.
15. Explanation for change in burden – N.A.
16. Time schedule for data collections and publications - The results of this collection will not be published.
17. Request to not display OMB expiration date - The forms in this collection are seldom revised. Given the costs associated with the redrafting, reprinting, and distribution of these forms, the RRB requests the authority to not display the expiration date on the forms.
18. Exceptions to Certification Statement - None
| File Type | application/msword |
| Author | Darlene D. Velez |
| File Modified | 2012-01-23 |
| File Created | 2011-09-28 |