Medicare

Forms and Documents

Document Name	Status
Form AA-6 (01-12) Medicare Form and Instruction	Modified
Form RL-311-F (01-18) Employer Coverage Under an Employer Group Health Plan Form and Instruction	Modified
3220-0082.doc Supporting Statement A	2018-04-18
Form CMS-L564 (09-16).pdf Supplementary Document	2018-04-17
Form G-346 (03-18).pdf Supplementary Document	2018-04-17
Form RL-9 (07-02).pdf Supplementary Document	2015-01-08
Form RB-20 (01-18).pdf Supplementary Document	2018-04-17
Form RB-3 (11-08).pdf Supplementary Document	2015-01-08

IC Document Collections

IC ID	Document Title	Status
33882	Medicare Form and Instruction	Modified
186948	Employer Coverage Under an Employer Group Health Plan Form and Instruction	Modified

ICR Details

OMB Control No: 3220-0082	ICR Reference No: 201804-3220-005
Status: Active	Previous ICR Reference No: 201501-3220-002
Agency/Subagency: RRB	Agency Tracking No:
Title: Medicare
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/06/2018
	Date Received in OIRA: 04/18/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2021	36 Months From Approved	06/30/2018
Responses	2,240	0	2,240
Time Burden (Hours)	365	0	365
Cost Burden (Dollars)	0	0	0

---

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.

---

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

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:
	83 FR 3779	01/26/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 14680	04/05/2018
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Medicare	AA-6 (01-12), AA-7 (01-12), AA-8 (01-12)	Employee Application for Medicare ,   Spouse/Divorced Spouse Application for Medicare ,   Widow/Widower Application for Medicare
Employer Coverage Under an Employer Group Health Plan	RL-311-F (01-18)	Evidence of Coverage Under an Employee Group Health Plan

---

ICR Summary 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	2,240	2,240	0	0	0	0
Annual Time Burden (Hours)	365	365	0	0	0	0
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: $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? Uncollected

---

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: 04/18/2018

---