Application for Hospital Insurance (CMS-18F5)

ICR 201804-0938-022

OMB: 0938-0251

Federal Form Document

IC Document Collections
IC ID
Document
Title
Status
7908 Modified
ICR Details
0938-0251 201804-0938-022
Active 201402-0938-013
HHS/CMS CM-CPC
Application for Hospital Insurance (CMS-18F5)
Reinstatement without change of a previously approved collection   No
Regular
Approved with change 08/01/2018
Retrieve Notice of Action (NOA) 04/25/2018
  Inventory as of this Action Requested Previously Approved
08/31/2021 36 Months From Approved
51,000 0 0
29,580 0 0
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 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
  
None

Not associated with rulemaking

  82 FR 31331 07/06/2017
82 FR 48719 10/19/2017
No

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

  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
No
No
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).

$846,114
No
    Yes
    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.
04/25/2018


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