Information Collection

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

IC 33999 under ICR 202311-3220-003 · OMB 3220-0185.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form RL-380-F (05-18) Report of Medicaid State Office on Beneficiary's Buy-In Status	Form
RL-380-F (05-18) Report of Medical State Office on Beneficiary's Buy-In S Form RL-380-F (05-18).pdf	Form
RL-380-F (05-18) Report of Medical State Office on Beneficiary's Buy-In S Form RL-380-F (05-18).pdf	Form
RL-380-F (Proposed Report of Medical Beneficiary's Buy-In Status Form RL-380-F (XX-XX).pdf	Form
RL-380-F (Proposed Report of Medical Beneficiary's Buy-In Status Form RL-380-F (XX-XX).pdf	Form
CMS-1957 (04-18).pdf Report of State Buy-In Problem	IC Document
CMS-1957 (04-18).pdf Report of State Buy-In Problem	IC Document

IC Title:

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 (05-18)	Report of Medical State Office on Beneficiary's Buy-In Status	Form RL-380-F (05-18).pdf		No		Paper Only
Form	RL-380-F (Proposed)	Report of Medical Beneficiary's Buy-In Status	Form RL-380-F (XX-XX).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

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	CMS-1957 (04-18).pdf	06/16/2020

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