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Federal forms, ICRs, and supporting documents

Information Collection Request

Application for Hospital Insurance

ICR 201402-0938-013 · OMB 0938-0251 · Historical Active

Forms and Documents
Document
Name
Status
Form
 Modified
Supplementary Document
2014-02-23
Supporting Statement A
2014-02-23
IC Document Collections
IC ID
Document
Title
Status
7908 Modified
ICR Details
0938-0251 201402-0938-013
Historical Active 201012-0938-021
HHS/CMS 21473
Application for Hospital Insurance
Extension without change of a currently approved collection   No
Regular
Approved without change 07/03/2014
Retrieve Notice of Action (NOA) 02/26/2014
  Inventory as of this Action Requested Previously Approved
07/31/2017 36 Months From Approved 07/31/2014
50,000 0 50,000
12,500 0 12,495
0 0 0
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.
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
   US Code: 42 USC 427 Name of Law: Transitional Insured Status
   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
  
None
Not associated with rulemaking
  78 FR 73545 12/06/2013
79 FR 8973 02/14/2014
No
  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) 12,500 12,495 0 0 5 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
The changes in burden are to correct miscalculation in the response time from the prior submission. The prior package indicated that 15 minutes was 0.2499 minutes, however, the proper calculation should be 0.25 minutes. When multiplied by the number of forms (50,000), there was an increase in 5 burden hours annually. This slight increase in burden hours when calculated to determine the annual cost burden resulted in an increase of $136.55. Since the last submission in 2010, there have been no increases in printing costs or the hourly rate of payment for the SSA representative collecting and processing the information.
$343,428
No
No
No
No
No
Uncollected
Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
02/26/2014