3220-0082

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 (45 U.S.C. 231f), 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 forms shown below.

• 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, or a telephone interview, with an applicant 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. Section 217.17(f)(3) (20 CFR §217.17(f)(3)) provides for an alternative signature.

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 Form G-346, Employee’s 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 in Part B and claim coverage under a GHP or to verify existing coverage for the individual claiming premium surcharge relief based on GHP coverage.

The RRB proposes the following changes to Form RL-311-F:

• Add the option to return the form by facsimile.

• Changed question 4 to replace working with employed, add an employment start date for the employee, and add additional instructions.

Note: This information is requested by CMS on their Form CMS-L564, Request for Employment Information (0938-0787).

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - None – Not cost effective due to low volume. Due to agency technology limitations, this information collection does not allow for electronic submission as described in the Government Paperwork Elimination Act (GPEA). However, we will reevaluate electronic signatures after the completion of our IT Modernization project.

4. Efforts to identify duplication – To our knowledge, no other agency uses a form similar to the forms in this collection and this information collection does not duplicate any other RRB 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 21362 of the April 22, 2021, 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 https://www.rrb.gov/sites/default/files/2017-06/PIA-BPO.pdf.

11. Sensitive questions - N.A.

12. Estimate of respondent burden - The current burden for this collection is shown below:

Current Burden

Form Number	Annual Responses	Time (Minutes)1/	Burden (Hours)
AA-6	180	8	24
AA-7	50	8	7
AA-8	10	8	1
RL-311-F	2,000	10	333
Total	2,240		365

1/The RRB has been collecting the information on these forms since OMB approved the information collection. Based on a sampling done when the form was originally created, the office calculated the estimated time, which includes time for getting the needed data and reviewing the completed form.

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 RRB started an extensive multi-year IT Modernization Initiative at the beginning of Fiscal Year 2019 to transform our operations into the 21^st Century using multiple contractor services to improve mission performance, expand service capabilities, and strengthen cybersecurity. In addition, we received a new Chief Information Officer (CIO) on September 2, 2019 who is reviewing our estimated project timeline milestone dates. We provided OMB with a consolidated project timeline.

Given that the forms in this collection are seldom revised; the costs associated with redrafting, reprinting, and distributing forms in order to keep the appropriate OMB expiration date in place; and our desire to reevaluate after the completion of the modernization project, the RRB requests the authority to not display the expiration date on the forms.

18. Exceptions to Certification Statement - None

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