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OMB Control No: 0938-0080	ICR Reference No: 201311-0938-008
Status: Historical Active	Previous ICR Reference No: 200908-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No: 20864
Title: Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13
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 without change	Conclusion Date: 04/21/2014
	Date Received in OIRA: 11/08/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved
Responses	60,000	0	0
Time Burden (Hours)	24,960	0	0
Cost Burden (Dollars)	0	0	0

Abstract: The form CMS-43 is used to establish entitlement to Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B) by individuals with End Stage Renal Disease (ESRD).

Authorizing Statute(s): US Code: 42 USC 426-1 Name of Law: Special Provisions Relating to Coverage Under Medicare Program for End Stage Renal Disease

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:
	78 FR 38986	06/28/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 61846	10/04/2013
Did the Agency receive public comments on this ICR? No

ICR Summary of Burden

	Total Approved	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	60,000	0	60,000
Annual Time Burden (Hours)	24,960	-1,030	25,990
Annual Cost Burden (Dollars)	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: While the number of respondents has not changed, we adjusted the response time from 26 min to 25 min (more specifically, 0.416 hr). Consequently, the total annual response time has been adjusted from 25,990 min to 24,960 min. The decrease in the burden cost by $14,770.40 results from an increase in printing costs, the hourly rate of pay for SSA employees who process the CMS-43 as well as errors in the cost calculations on the last Supporting Statement provided in 2009. The burden increases by $2,692 over the last submission because of the increase in printing costs. However, this increase is offset by a decrease of $17,462.40 from the last submission because of errors in the cost calculations. In addition, the hourly rate of payment from the SSA representatives collecting and processing the information has increased by $0.41 from $26.90 per hour to $27.31 per hour.

Annual Cost to Federal Government: $685,850

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

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