Medicare

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form AA-8 (01-18) Curre Widow Widower Application for Medicare - Medical Insurance (Part B) Program	Form and Instruction	Modified	Available
Form AA-7 (01-18) Curre Spouse Divorced Spouse Application for Medicare	Form and Instruction	Modified	Available
Form AA-6 (01-18) Curre Employee Application for Medicare	Form and Instruction	Modified	Repair queued
Form AA-24 (XX-XX) Prop Application for Medicare Part B - Exceptional Conditions	Form and Instruction	Modified	Available
Form AA-23 (XX-XX) Prop Application for Medicare - Medical Insurance (Part B)	Form and Instruction	Modified	Available
Form AA-8 (XX-XX) Propo Widow Widower Application for Medicare - Medical Insurance (Part B) Program	Form and Instruction	Modified	Available
Form AA-7 (XX-XX) Propo Spouse Divorced Spouse Application for Medicare	Form and Instruction	Modified	Available
Form AA-6 (XX-XX) Propo Employee Application for Medicare	Form and Instruction	Modified	Available
Form AA-6 (XX-XX) Propo Medicare	Form and Instruction	Modified	Repair queued
Form RL-311F (XX-XX) Pr Evidence of Coverage Under an Employee Group Health Plan	Form and Instruction	Modified	Available
Form RL-311F (08-22) Cu Evidence of Coverage Under an Employee Group Health Plan	Form and Instruction	Modified	Available
Form RL-311F (08-22) Cu Employer Coverage Under an Employer Group Health Plan	Form and Instruction	Modified	Missing upstream
3220-0082_Final.docx	Supporting Statement A	Uploaded 2025-04-02	Repair queued
3220-0082_Final.docx	Supporting Statement A	Uploaded 2025-04-02	Repair queued
Request OMB Approval of NonSubstatative Change to ICR 3220-0082_Signed.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2022-06-08	Repair queued
Request OMB Approval of NonSubstatative Change to ICR 3220-0082_Signed.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2022-06-08	Repair queued
CMS-L564(8-20).pdf	Supplementary Document	Uploaded 2021-06-29	Repair queued
CMS-L564(8-20).pdf	Supplementary Document	Uploaded 2021-06-29	Repair queued
Form G-346 (03-18).pdf	Supplementary Document	Uploaded 2018-04-17	Repair queued
Form G-346 (03-18).pdf	Supplementary Document	Uploaded 2018-04-17	Repair queued
Form RL-9 (07-02).pdf	Supplementary Document	Uploaded 2015-01-08	Repair queued
Form RL-9 (07-02).pdf	Supplementary Document	Uploaded 2015-01-08	Missing upstream
Form RB-20 (01-18).pdf	Supplementary Document	Uploaded 2018-04-17	Repair queued
Form RB-20 (01-18).pdf	Supplementary Document	Uploaded 2018-04-17	Repair queued
Form RB-3 (11-08).pdf	Supplementary Document	Uploaded 2015-01-08	Repair queued
Form RB-3 (11-08).pdf	Supplementary Document	Uploaded 2015-01-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
33882	Medicare	Form and Instruction	Modified	Widow Widower Application for Medicare - Medical Insurance (Part B) Program
33882	Medicare	Form and Instruction	Modified	Spouse Divorced Spouse Application for Medicare
33882	Medicare	Form and Instruction	Modified	Employee Application for Medicare
33882	Medicare	Form and Instruction	Modified	Application for Medicare Part B - Exceptional Conditions
33882	Medicare	Form and Instruction	Modified	Application for Medicare - Medical Insurance (Part B)
33882	Medicare	Form and Instruction	Modified	Widow Widower Application for Medicare - Medical Insurance (Part B) Program
33882	Medicare	Form and Instruction	Modified	Spouse Divorced Spouse Application for Medicare
33882	Medicare	Form and Instruction	Modified	Employee Application for Medicare
33882	Medicare	Form and Instruction	Modified
186948	Employer Coverage Under an Employer Group Health Plan	Form and Instruction	Modified	Evidence of Coverage Under an Employee Group Health Plan
186948	Employer Coverage Under an Employer Group Health Plan	Form and Instruction	Modified	Evidence of Coverage Under an Employee Group Health Plan
186948	Employer Coverage Under an Employer Group Health Plan	Form and Instruction	Modified

ICR Details

OMB Control No: 3220-0082	ICR Reference No: 202411-3220-012
Status: Historical Active	Previous ICR Reference No: 202206-3220-004
Agency/Subagency: RRB	Agency Tracking No:
Title: Medicare
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: 05/13/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/02/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2028	36 Months From Approved
Responses	3,840	0	0
Time Burden (Hours)	578	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Railroad Retirement Board administers the Medicare program for persons covered by the railroad retirement system. The forms in the collection obtain both information needed to enroll non-retired employees and survivor applicants in the plan and information from railroad employers needed to determine if a railroad retirement beneficiary is entitled to a special enrollment period when applying for supplemental medical coverage under Medicare.

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Authorizing Statute(s): US Code: 45 USC 231f(d) Name of Law: Railroad Retirement Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 8165	01/24/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 14172	03/28/2025
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Employer Coverage Under an Employer Group Health Plan	RL-311F (08-22) Current, RL-311F (XX-XX) Proposed	Evidence of Coverage Under an Employee Group Health Plan ,   Evidence of Coverage Under an Employee Group Health Plan
Medicare	AA-6 (01-18) Current, AA-7 (XX-XX) Proposed, AA-6 (XX-XX) Proposed, AA-8 (XX-XX) Proposed, AA-24 (XX-XX) Proposed, AA-23 (XX-XX) Proposed, AA-7 (01-18) Current, AA-8 (01-18) Current	Employee Application for Medicare ,   Spouse Divorced Spouse Application for Medicare ,   Widow Widower Application for Medicare - Medical Insurance (Part B) Program ,   Application for Medicare - Medical Insurance (Part B) ,   Application for Medicare Part B - Exceptional Conditions ,   Employee Application for Medicare ,   Spouse Divorced Spouse Application for Medicare ,   Widow Widower Application for Medicare - Medical Insurance (Part B) Program

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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	3,840	0	0	1,600	0	2,240
Annual Time Burden (Hours)	578	0	0	213	0	365
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The overall annual responses increased from 2,240 to 3,840 and overall burden hours increased from 365 to 368 due to adding Forms AA-23 and AA-24 to the clearance.

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Annual Cost to Federal Government: $0

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.     Yes

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

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Common Form ICR:  No

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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: 04/02/2025

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