3220-0185

OMB NO. 3220-0185

Justification

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

RRB Form RL-380-F

1. Circumstances of the collection - Under Section 7(d) of the Railroad Retirement Act, the Railroad Retirement Board (RRB) administers the Medicare program for persons covered by the railroad retirement system. Under Section 1843 of the Social Security Act, States may enter into “buy-in agreements” with the Secretary of Health and Human Services for the purpose of enrolling certain groups of low-income individuals under the Medicare medical insurance (Part B) program and paying the premiums for their insurance coverage. Generally, these individuals are categorically needy under Medicaid and meet the eligibility requirements for Medicare Part B. States can also include in their buy-in agreements, individuals who are eligible for medical assistance only.

The regulations pertaining to State buy-in (SBI) agreements and the various categories of individuals covered under such agreements are contained in 42 CFR 407.

2. Purposes of collecting/consequences of not collecting the information - In some cases, railroad retirement beneficiaries are entitled to receive Part B coverage under an SBI agreement entered into by the States in which they reside. In these cases, the particular States that are a party to such agreements are responsible for the payment of the Medicare medical insurance (Part B) premium, rather that the beneficiary. In the absence of any buy-in agreement, beneficiaries in any of the needy group categories are required to pay for their own Part B premiums through direct premium remittance or through deductions taken from their monthly RRB payments.

Although a particular State may enter into a SBI agreement, no actual “buy-in” occurs until that State pays the premium for a beneficiary and establishes a record for that individual on the Centers for Medicare & Medicaid Services (CMS) Third Party Master Record System.

RRB field offices occasionally receive reports of a buy-in problem for a beneficiary. In most instances, RRB field offices learn of the problem through a verbal or written beneficiary complaint. However, reports of buy-in problems can also be received from other sources, including State Medicaid offices, CMS, and the insurance carrier responsible for administering the Part B program.

The RRB utilizes Form RL-380-F, Report of Medicaid State Office on Beneficiary’s Buy-In Status, to resolve a beneficiary’s complaint or problem reported by State Medicaid offices, CMS or other sources regarding a State buy-in situation. The top portion of the form showing the beneficiary’s identifying information is completed by the RRB field office representative, who also enters his or her signature, title, office phone number and date in the spaces provided. The form is then mailed from the RRB field office to the State Medicaid office which completes the bottom portion of the form by checking one or more of the 11 items provided on the form. After the form is completed, it is signed by the state Medicaid representative who completed the form. The representative also enters his or her title, date and telephone number. The completed form is returned to the RRB field office that initiated the request. If the RRB field office receives no response from the State Medicaid office within 60 days after release of Form RL-380-F, the field office releases a second form stamped “second request” to the same State Medicaid office. Upon receipt of a completed Form RL-380-F, the RRB field office advises the beneficiary or the other source of the State’s response relating to the buy-in status of the beneficiary.

The Form RL-380-F provides the RRB with an efficient method for investigating and resolving SBI problems within a 3-month time period because of the direct contact involved between the RRB field offices and the State Medicaid offices. Consequently, the beneficiary or other source that initiated the SBI inquiry receives a response in a timely manner which may prevent multiple monthly premiums being due.

The RRB proposes no changes to Form RL-380-F.

Form RL-380-F is similar to Form CMS-1957, SSO Report of State Buy-In Problem, OMB No. 0938-0035.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction – None planned: not cost effective because of low volume. Also, the form is issued by the RRB only in very specific situations with a considerable amount of prefilled information.

4. Efforts to identify duplication and other improvements - This information collection does not duplicate any other information collection.

5. Small business respondents - N.A.

6. Consequences of less frequent collection - Not applicable since the information is obtained only once for each case.

7. Special circumstances - None.

8. Consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding the information collection. The notice to the public was published on page 79076 of the December 17, 2010 Federal Register. No comments or requests for additional information were received.

9. Payments or gifts to respondents - None.

10. Confidentiality - Privacy Act System of Records, RRB-20, Health Insurance and Supplementary Medical Insurance Enrollment and Premium Payment System (MEDICARE). In accordance with OMB Circular M-03-22, a Privacy Impact Assessment for this information collection was completed and can be found at http://www.rrb.gov/pdf/PIA/PIA-BPO.pdf.

11. Sensitive questions - None.

12. Estimate of respondent burden -We estimate that an average of 50 Forms RL-380- F are released by RRB field offices to State Welfare offices on a monthly basis, or approximately 600 forms per year. Past experience indicates that on average, 1 or 2 boxes require completion by the State Welfare offices. We estimate an average completion time of 10 minutes for the form, resulting in an estimated reporting burden of 100 hours annually.

13. Estimated annual cost to respondents or record keepers - N.A.

14. Estimate of cost to Federal Government - N.A.

15. Explanation for changes in burden - N.A.

16. Time schedule for data collections and publications - The results of this collection will not be published.

17. Request not to display OMB expiration date - The form associated with this collection is seldom revised. Given the costs associated with redrafting, reprinting, and distributing the form in order to keep the appropriate expiration date in place, the RRB requests the authority to not display the OMB expiration date on the form.

18. Exceptions to Certification Statement - None