Employer Coverage Under an Employer Group Health Plan

Medicare

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0082 can be found here:

Documents and Forms

Document Name Document Type
Form RL-311-F (03-10) Employer Coverage Under an Employer Group Health Plan Form and Instruction
RL-311-F (03-10) Evidence of Coverage Under an Employee Group Health Plan Form RL-311-F (03-10).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Employer Coverage Under an Employer Group Health Plan	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 406 & 407

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	RL-311-F (03-10)	Evidence of Coverage Under an Employee Group Health Plan	Form RL-311-F (03-10).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: RRB-20, Health Insurance and Supplementary Medical Insurance Enrollment and Premium Payment System (MEDICARE)	FR Citation: 79 FR 58874

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,000	1,200	800
Annual IC Time Burden (Hours)	333	200	133
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.