Medicare Request for Retirement Benefit Information (CMS-R-285)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-R-285 Request for Retirement Benefit Information	Form	Modified	Available
Form CMS-R-285 Request for Retirement Benefit Informatin	Form	Modified	Repair queued
CMS-R-285 - Supporting Statement A_.docx	Supporting Statement A	Uploaded 2024-08-07	Available
CMS-R-285 - Supporting Statement A_.docx	Supporting Statement A	Uploaded 2024-08-07	Repair queued
Mississippi Department of Human Services.pdf	Public Comments	Uploaded 2024-06-17	Repair queued
Response to Comments OMB 0938 0769.docx	Supplementary Document	Uploaded 2024-08-06	Available
Response to Comments OMB 0938 0769.docx	Supplementary Document	Uploaded 2024-08-06	Repair queued
Crosswalk of Changes CMS R285_508.pdf	Supplementary Document	Uploaded 2024-08-06	Repair queued
Crosswalk of Changes CMS R285_508.pdf	Supplementary Document	Uploaded 2024-08-06	Repair queued
Justification - Use of SSN.docx	Supplementary Document	Uploaded 2013-09-08	Available
Justification - Use of SSN.docx	Supplementary Document	Uploaded 2013-09-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8511	Request for Retirement Benefit Informatin	Form	Modified	Request for Retirement Benefit Information
8511	Request for Retirement Benefit Informatin	Form	Modified

ICR Details

OMB Control No: 0938-0769	ICR Reference No: 202408-0938-005
Status: Active	Previous ICR Reference No: 202012-0938-017
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Medicare Request for Retirement Benefit Information (CMS-R-285)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/15/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/08/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2027	36 Months From Approved
Responses	500	0	0
Time Burden (Hours)	125	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This information is needed to determine whether a beneficiary meets the requirements for reduction of the Part A premium to zero.

---

Authorizing Statute(s): Statute at Large: 18 Stat. 1818
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 27764	04/18/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 64465	08/07/2024
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Request for Retirement Benefit Informatin	CMS-R-285	Request for Retirement Benefit Information

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	500	0	0	0	0	500
Annual Time Burden (Hours)	125	0	0	0	0	125
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $2,470

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/08/2024

---