Application for Hospital Insurance (CMS-18F5)

Forms and Documents

Document Name	Status
Form CMS-18F5 Application for Hospital Insurance Form	Modified
CMS-18F5.Supporting Statement Part A - FINAL 7-27-18.docx Supporting Statement A	2018-07-27
Justification for Collecting Social Security Numbers CMS 18F5 0938-0251.pdf Supplementary Document	2018-04-24

IC Document Collections

IC ID	Document Title	Status
7908	Application for Hospital Insurance Form	Modified

ICR Details

OMB Control No: 0938-0251	ICR Reference No: 201804-0938-022
Status: Active	Previous ICR Reference No: 201402-0938-013
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Application for Hospital Insurance (CMS-18F5)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/01/2018
	Date Received in OIRA: 04/25/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2021	36 Months From Approved
Responses	51,000	0	0
Time Burden (Hours)	29,580	0	0
Cost Burden (Dollars)	0	0	0

---

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.

---

Authorizing Statute(s): 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
   US Code: 42 USC 1395i-2a Name of Law: Hospital Insurance Benefits for Disabled Individuals Who Have Exhausted Other Entitilements
   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

---

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:
	82 FR 31331	07/06/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 48719	10/19/2017
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Application for Hospital Insurance	CMS-18F5, CMS-18F5(SP)	CMS-18F5.Application for Hospital Insurance (7-27-18) ,   CMS-18F5_SP. Solicitud Para El Seguro De Hospital

---

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	51,000	0	0	0	1,000	50,000
Annual Time Burden (Hours)	29,580	0	0	0	17,080	12,500
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: We are adjusting our burden estimates. This is a result of an increase in the estimated time (based on actual experience) it takes for SSA to collect and process the information on Form CMS-18F5. The burden also increased due to improved methods to approximate number of respondents using the Medicare Beneficiary Database (MBD). It was previously estimated that is takes respondents 15 minutes (0.25 hr) to complete the form. Based on actual experience by SSA representatives, we now estimate 35 minutes (0.58 hr) per response, an increase of 20 minutes each. This accounts for the time it takes to complete the form during an in-person interview with an SSA representative. The burden also increased due to improved methods to approximate number of respondents using the Medicare Beneficiary Database (MBD). The data provided an increase of 1,000 respondents, not a significant increase from the 2013 approved submission. The overall burden increased from 12,500 hours (50,000 respondents x 0.25 hr/response) in 2013 to 29,580 hours (51,000 respondents x 0.58 hr/response).

---

Annual Cost to Federal Government: $846,114

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.     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

---

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: 04/25/2018

---