Information Collection

Report of Medicaid State Office on Beneficiary's Buy-In Status

IC 33999 under ICR 202006-3220-004 · OMB 3220-0185.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0185 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form RL-380-F (01-17) Report of Medical State Office on Beneficiary's Buy-In Status Report of Medicaid State Office on Beneficiary's Buy-In Status	Form
Form RL-380-F (Proposed Report of Medical Beneficiary's Buy-In Status Report of Medicaid State Office on Beneficiary's Buy-In Status	Form
RL-380-F (01-17) Report of Medical State Office on Beneficiary's Buy-In S Form RL-380-F (01-17).pdf	Form
RL-380-F (Proposed Report of Medical Beneficiary's Buy-In Status Form RL-380-F (XX-XX) - Proposed.pdf	Form
CMS-1957 (04-18).pdf Report of State Buy-In Problem	IC Document

IC Title:

Report of Medicaid State Office on Beneficiary's Buy-In Status

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 407

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	RL-380-F (01-17)				No		Paper Only
Form	RL-380-F (Proposed)				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

FR Citation: 79 FR 58874

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Report of State Buy-In Problem		06/16/2020

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].