CMS-10902_Supporting Statement Part A

Supporting Statement Part A

Environmental Health Hazards Checklist Medicare Coverage for Individuals Exposed to Environmental Health Hazards

(CMS-10902, OMB 0938-NEW)

Background

This 2024 iteration is a new request. There are no previous iterations or submissions. This form is currently in use and this data has been collected since 2010, however, it has been in use without an OMB control number. During the course of litigation and subsequent examination of this checklist, CMS realized that due to administrative oversight, the checklist had not undergone Paperwork Reduction Act review. CMS immediately started the process to rectify the error.

On July 30, 1965, P.L. 89-97 created Title XVIII of the Social Security Act (the Act). Title XVIII established the hospital insurance program (also referred to as Part A) and the supplementary medical insurance (SMI) program (also referred to as Part B).

Part B is a voluntary program and is financed from premium payments by enrollees together with contributions from funds appropriated by the Federal government. All individuals age 65 or older who are entitled to Part A can enroll in Part B. There are some individuals, age 65 and over, who are not entitled to or eligible for premium-free Part A. These individuals may, however, pay a premium for Part A and/or enroll in Part B only.

Section 10323 of the Patient Protection and Affordable Care Act amended Title XVIII of the Act (42 U.S.C. 1395, et seq.) to establish Medicare eligibility for persons who have been affected by environmental exposure to asbestos prior to June 17, 2009, in a geographic area subject to an emergency declaration. The form Environmental Health Hazards Checklist (CMS-10902) is used by the Social Security Administration (SSA) to determine if an individual meets the eligibility criteria to establish entitlement to Hospital Insurance (Part A) and enrollment in Supplementary Medical Insurance (Part B) on the basis of an Environmental Health Hazard. Completed by a licensed provider, the CMS-10902 provides proof that an applicant was present in Lincoln County, Montana and has an asbestos-related condition. This form is available in both English and Spanish.

A. Justification

1. Need and Legal Basis

Section 1881A of the Act provides an enrollment basis for individuals who have been exposed to environmental health hazards. Currently, the only individuals eligible for Medicare under this provision are those who were present in Lincoln County, Montana, and have an asbestos-related disease (ARD) diagnosis. Eligible individuals must be diagnosed with one or more asbestos-related conditions and have been present in Lincoln County, Montana, for a total of at least 6 months (need not be consecutive) in the period ending 10 years or more before diagnosis of an asbestos-related condition. This form provides verification from a provider so that SSA can determine eligibility for Medicare enrollment.

2. Information Users

SSA uses this information to determine whether an individual meets the requirements for Medicare enrollment on the basis of an Environmental Health Hazard. CMS does not collect or store the information collected.

3. Use of Information Technology

Instructions are provided on the form and it is completed by SSA and a licensed provider. It is also available in Spanish. The form is faxed to the applicant’s provider by SSA. The provider must complete and sign the form and submit it back to SSA via fax or mail. The information on the completed form is reviewed manually by SSA.

The form consists of three steps that must be completed to determine an individual’s eligibility for Medicare.

Step 1 on the Environmental Health Hazards Checklist (completed by SSA)

SSA completes Step 1 by filling in three fields. They are as follows:

1. First Name – Middle initial – Last Name

2. Social Security Number

3. Date of Birth

Step 2 on the Environmental Health Hazards Checklist (completed by Provider)

Requests the Provider to check the box next to the individual’s diagnosed asbestos-related condition and to provide the date of diagnosis.

The options are as follows:

• Asbestosis

• Pleural Thickening/Pleural Plaques

• Mesothelioma

• Malignancy of the lung, colon, rectum, larynx, stomach, esophagus, pharynx and/or ovary

Step 3 on the Environmental Health Hazards Checklist (completed by Provider)

Requests the provider to provide the dates the individual was present in the area that is subject to the environmental health hazard and indicate if it was for the required amount of time.

Lastly, a signature is required from the provider attesting that the information provided is accurate.

4. Duplication of Efforts

The collection of this information does not duplicate any other effort.

4. Small Businesses

Small businesses are not affected by the collection of this information.

6. Less Frequent Collection

This information is collected only as needed. Less frequent collection would adversely affect beneficiary’s eligibility for Medicare enrollment since they’re only allowed to enroll using on this basis if the provider verifies eligibility based on condition and residence.

7. Special Circumstances

There are no special circumstances that would require an information collection to be conducted in a manner that requires respondents to:

• Report information to the agency more often than quarterly;

• Prepare a written response to a collection of information in fewer than 30 days after receipt of

it;

• Submit more than an original and two copies of any document;

• Retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;

• Collect data in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• Use a statistical data classification that has not been reviewed and approved by OMB;

• Include a pledge of confidentiality that is not supported by authority established in statute or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• Submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

8. Federal Register/Outside Consultation

The 60-day notice published in the Federal Register on 9/5/2024 (89 FR 72402).

No comments were received during the 60-day comment period.

The 30-day notice published in the Federal Register on 11/22/2024 (89 FR 92689).

9. Payments/Gifts to Respondents

This form provides the evidence necessary to determine eligibility for Medicare on the basis of an Environmental Health Hazard. There are no payments or gifts to respondents.

10. Confidentiality

The information collected is protected under provisions of the Privacy Act. A copy of the information collected is provided to the applicant. System of Records Notice (SORN) that apply to Medicare claims:

• 60-0090 - SSA’s Master Beneficiary Record (MBR).

11. Sensitive Questions

There are no sensitive questions associated with this collection. Specifically, the collection does not solicit questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. However, the collection solicits questions such as SSN and the provider has to disclose a specific diagnosis.

12. Burden Estimates (Hours & Wages)

12.1. Wage Estimates

The burden is computed as follows:

Annually, there are approximately 61 applicants who will require form CMS-10902. Based on the limited information requested for completion by the provider on the form, we estimate that it takes a provider on average 10 minutes to complete.

In aggregate, the burden for 61 applicants to complete the form is 10.37 hours ((61 x 0.17 (10 minutes) = 10.37 hours).

To derive average costs for individuals, we used data from the U.S. Bureau of Labor Statistics’ May 2023 National Occupational Employment and Wage Estimates for our salary estimate (www.bls.gov/oes/current/oes_nat.htm). We believe that the burden will be addressed under Health Practitioners (occupation code 29-0000) at $38.86/hr since the group of individual respondents varies widely from specialty and experience and by respondent age, location, years of employment, and educational attainment, etc.

We calculated fringe benefits at $38.86 for a total wage of $77.72/hr. (double the salary)

12.2. Burden Estimates

There are approximately 61 applicants who use Form CMS-10902. Based on the information requested for completion by the applicant on the form, we estimate that it takes a provider on average 10 (.17 hrs) minutes to complete.

The burden is computed as follows:

We estimate an annual burden of 10.37 hours (61 respondents x 0.17 hours) at a cost of $805.96 (10.37 hr x $77.72/hr) or $13.21 per respondent ($805.96/61 respondents).

Number of applications	Time required	Total Annual Burden	Wage Cost	Cost of Fringe Benefits	Total Cost
61	0.17	10.37 hours	$38.86	$38.86	$805.96

*Figures are estimates.

CMS is soliciting public comments on the provider burden estimates to verify their accuracy.12.3. Information Collection Instruments and Supporting Documents

• Environmental Health Hazards Checklist

The form is available upon request from SSA. The form includes instructions for completion.

Policies for SSA to process a received form are outlined in HI 00803.050 (Developing

Medical Requirement for Entitlement to EHH Medicare) at https://secure.ssa.gov/poms.nsf/lnx/0600803050

13. Capital Costs

There are no capital costs.

14. Cost to Federal Government

We estimate it will take a federal government employee 10 minutes to review and record the collected data.

It is calculated that the burden hours for 61 responses to be reviewed and recorded in 10 minutes per response to be 10 total hours ((61x 0.17 (10 minutes) = 10.37 total burden hours). SSA must first locate and fax/mail/email the form to the provider. Once the form is returned to SSA from the provider, SSA must then review and determine eligibility for the individual.

To derive average costs, we used data from the Office of Personnel Management 2024

General Schedule (GS) Locality Pay Table for all salary estimates

(https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/2024/general-

schedule). We estimate that the average government employee at SSA to receive and record the collected data to be a Grade 11, Step 5 (GS-11-5) – which we believe is the most appropriate level for a SSA field office representative.

As the processing of this form occurs at the national level and not just one geographic location, we estimated the salary using the national base general schedule. Such an hourly wage is $33.73/hr or $70,387 annually. Therefore, the total cost to the government to complete the annual volume of responses is $349.78 (10.37 hours x $33.73/hr = $349.78).

Number of applications		Wage Cost	Time required		Total
	61	$33.73		0.17	$349.78

*Figures are estimates.

15. Program and Burden Changes

This is a new collection.

15. Publication/Tabulation Dates

There are no plans to publish or tabulate the information collected.

15. Expiration Date

The form displays the expiration date next to the OMB control number.

15. Certification Statement

There are no exceptions to the certification statement.

B. Collection of Information Employing Statistical Methods

Not applicable. There are no statistical methods.

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