Application for Enrollment in Medicare Part A, Internet Claim (iClaim) Application Screen, Modernized Claims System and Consolidated Claim (CMS-18F5)

Forms and Documents

Document Name	Status
Form CMS-18F5 Application for Part A (Hospital Insurance) Form	Modified
Form CMS-18F5 Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE)) Form and Instruction	New
Crosswalk of_ Changes.pdf Supplementary Document	2021-02-12
CMS-18F5 - Supporting Statement A.docx Supporting Statement A	2021-02-12
Justification for Collecting Social Security Numbers.pdf Supplementary Document	2021-02-12

IC Document Collections

IC ID	Document Title	Status
7908	Application for Part A (Hospital Insurance) Form	Modified
245774	Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE)) Form and Instruction	New
245773	Internet Claim (iClaim) Application	New

ICR Details

OMB Control No: 0938-0251	ICR Reference No: 202102-0938-008
Status: Received in OIRA	Previous ICR Reference No: 201804-0938-022
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Application for Enrollment in Medicare Part A, Internet Claim (iClaim) Application Screen, Modernized Claims System and Consolidated Claim (CMS-18F5)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/16/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	08/31/2021
Responses	1,394,264	51,000
Time Burden (Hours)	348,566	29,580
Cost Burden (Dollars)	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 1935i-2 Name of Law: Hospital Insurance Benefits for Uninsured Elderly Individuals not Otherwise Eligible
   US Code: 42 USC 426 Name of Law: Entitlement to Hospital Insurance Benefits
   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

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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:
	85 FR 78333	12/04/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 9349	02/12/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Application for Part A (Hospital Insurance)	CMS-18F5	Application for Part A (Hospital Insurance)
Internet Claim (iClaim) Application
Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE))	CMS-18F5	Interview/SSA Claim System

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ICR Summary of Burden

	Total Request	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	1,394,264	51,000	0	1,393,568	-50,304	0
Annual Time Burden (Hours)	348,566	29,580	0	348,392	-29,406	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This significant increase is a result of improved data provided by SSA, in addition to the transfer of the information technology collection instruments from SSA to CMS. CMS will begin reporting for additional collection instruments, including the Internet Claim System (iClaim) and the Modernized Claims System (MCS) soon to be upgraded to the Consolidated Claims Experience (CCE). The hourly burden from the 2017 approved submission increased from 12,500 hours to 146,673 hours -- a change of 134,173.

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Annual Cost to Federal Government: $4,285,785

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? No

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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: 02/10/2021

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