Application for Hospital Insurance

Forms and Documents

Document Name	Status
Form CMS-18F5SP Application for Hospital Insurance and Supporting Regulations in 42 CFR 406.6, 406.7,406.10,406.11 and 406.20 Form and Instruction	Modified
CMS-18F5OMBsst2010.pdf Supporting Statement A	2010-12-30

IC Document Collections

IC ID	Document Title	Status
7908	Application for Hospital Insurance and Supporting Regulations in 42 CFR 406.6, 406.7,406.10,406.11 and 406.20 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0251	ICR Reference No: 201012-0938-021
Status: Historical Active	Previous ICR Reference No: 200708-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Application for Hospital Insurance
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: 03/14/2011
	Date Received in OIRA: 12/30/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2014	36 Months From Approved	03/31/2011
Responses	50,000	0	50,000
Time Burden (Hours)	12,495	0	12,495
Cost Burden (Dollars)	0	0	0

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Abstract: The form CMS 18 (and 18SP) is used to establish entitlement to Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B) by individuals who do not qualify for entitlement based upon entitlement to a Social Security or Railroad Retirement benefits.

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Authorizing Statute(s): US Code: 42 USC 427 Name of Law: Transitional Insured Status
   US Code: 42 USC 1395i-2a Name of Law: Hospital Insurance Benefits for Disabled Individuals Who Have Exhausted Other Entitilements
   US Code: 42 USC 426 Name of Law: Entitlement to Hospital Insurance Benefits
   US Code: 42 USC 1935i-2 Name of Law: Hospital Insurance Benefits for Uninsured Elderly Individuals not Otherwise Eligible
   PL: Pub.L. 42 - 406 10 Name of Law: Hospital Insurance Eligibility and Entitlement
   PL: Pub.L. 42 - 406 11 Name of Law: Individual age 65 or over who is not eligible as a social security or railroad retirement benefits
   PL: Pub.L. 42 - 406 20 Name of Law: Premium Hospital Insurance - Basic Requirements
   PL: Pub.L. 42 - 406 6 Name of Law: Application or enrollment for hospital insurance
   PL: Pub.L. 42 - 406 7 Name of Law: Forms to apply for entitlement under Medicare Part A
  

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:
	75 FR 62401	10/08/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 78999	12/17/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Application for Hospital Insurance and Supporting Regulations in 42 CFR 406.6, 406.7,406.10,406.11 and 406.20	CMS-18F5SP, CMS-18F5	SOLICITUD PARA EL SEGURO DE HOSPITAL ,   Application for Hospital Insurance

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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	50,000	50,000	0	0	0	0
Annual Time Burden (Hours)	12,495	12,495	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:

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Annual Cost to Federal Government: $343,291

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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

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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: 12/30/2010

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