Information Collection

Employer Coverage Under an Employer Group Health Plan

IC 186948 under ICR 202411-3220-012 · OMB 3220-0082.

Documents and Forms

Document Name Document Type
Form RL-311F (08-22) Cu Employer Coverage Under an Employer Group Health Plan Form and Instruction
RL-311F (08-22) Cu Evidence of Coverage Under an Employee Group Health Plan Form RL-311F (08-22).pdf Form and Instruction
RL-311F (08-22) Cu Evidence of Coverage Under an Employee Group Health Plan Form RL-311F (08-22).pdf Form and Instruction
RL-311F (XX-XX) Pr Evidence of Coverage Under an Employee Group Health Plan Form RL-311F Evidence of Coverage Under An Employer Group Health Plan (XX-XX) Proposed.pdf Form and Instruction
RL-311F (XX-XX) Pr Evidence of Coverage Under an Employee Group Health Plan Form RL-311F Evidence of Coverage Under An Employer Group Health Plan (XX-XX) Proposed.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Employer Coverage Under an Employer Group Health Plan	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 406 42 CFR 407

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	RL-311F (08-22) Current	Evidence of Coverage Under an Employee Group Health Plan	Form RL-311F (08-22).pdf		No		Paper Only
Form and Instruction	RL-311F (XX-XX) Proposed	Evidence of Coverage Under an Employee Group Health Plan	Form RL-311F Evidence of Coverage Under An Employer Group Health Plan (XX-XX) Proposed.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 (MEDICARE)	FR Citation: 79 FR 58874

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	333	333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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