CMS-R-285 - Supporting Statement part A [rev 9-8-2013 by OSORA PRA]

Supporting Statement Part A

_{Request for Retirement Benefit Information}

CMS-R-285, OCN 0938-0769

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.

_{A. Justification}

1. Need and Legal Basis

Section 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

The 60-day Federal Register notice published on June 21, 2013 (78 FR 37542). 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)

$1,875. ($15 per hour multiplied by 125 hours). The approximate number of respondents is 500. We estimate it will take 15 minutes to complete the form (500 x 0.25 = 125 hours).

_{13. Capital Costs}

There are no capital costs.

14. Cost to Federal Government

_{There is no cost to the Federal Government.}

_{15. Changes to Burden}

Our cost estimate has been adjusted as it decreased from $5,626 to $1,875. This is a result of decreased need and usage for this form as the number of state and local government entities providing pension retirement plans is decreasing. Specifically, in 2009 we estimated 1,500 respondents; in this 2013 package we adjust that estimate to 500 respondents. Please note that the time per response has not changed.

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.

B. Collection of Information Employing Statistical Methods

Requirements for this data collection do not employ statistical methods.

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