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Report of Medicaid State Office on Beneficiary's Buy-In Status
Report of Medicaid State Office on Beneficiary's Buy-In Status
OMB: 3220-0185
IC ID: 33999
OMB.report
RRB
OMB 3220-0185
ICR 202311-3220-003
IC 33999
( )
Documents and Forms
Document Name
Document Type
Form RL-380-F (05-18)
Report of Medicaid State Office on Beneficiary's Buy-In Status
Form
RL-380-F (05-18) Report of Medical State Office on Beneficiary's Buy-In S
Form RL-380-F (05-18).pdf
Form
RL-380-F (05-18) Report of Medical State Office on Beneficiary's Buy-In S
Form RL-380-F (05-18).pdf
Form
RL-380-F (Proposed Report of Medical Beneficiary's Buy-In Status
Form RL-380-F (XX-XX).pdf
Form
RL-380-F (Proposed Report of Medical Beneficiary's Buy-In Status
Form RL-380-F (XX-XX).pdf
Form
CMS-1957 (04-18).pdf
Report of State Buy-In Problem
IC Document
CMS-1957 (04-18).pdf
Report of State Buy-In Problem
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Report of Medicaid State Office on Beneficiary's Buy-In Status
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
42 CFR 407
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
RL-380-F (05-18)
Report of Medical State Office on Beneficiary's Buy-In Status
Form RL-380-F (05-18).pdf
No
Paper Only
Form
RL-380-F (Proposed)
Report of Medical Beneficiary's Buy-In Status
Form RL-380-F (XX-XX).pdf
No
Paper Only
Federal Enterprise Architecture Business Reference Module
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
FR Citation:
79 FR 58874
Number of Respondents:
600
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
600
0
0
0
0
600
Annual IC Time Burden (Hours)
100
0
0
0
0
100
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Report of State Buy-In Problem
CMS-1957 (04-18).pdf
06/16/2020
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.