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View ICR - OIRA Conclusion

OMB Control No: 0938-1179	ICR Reference No: 201906-0938-008
Status: Historical Active	Previous ICR Reference No: 201509-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Medicare Enrollment Application- Reassignment of Medicare Benefits (CMS-855R)
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: 01/06/2020
	Date Received in OIRA: 06/21/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2023	36 Months From Approved
Responses	357,628	0	0
Time Burden (Hours)	89,408	0	0
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	357,628	-21,991	379,619
Annual Time Burden (Hours)	89,408	-5,497	94,905
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: The total burden is 89,408 hours. Due to better reporting methods and more accurate data collection via PECOS, CMS is seeking approval of new burden estimates based on current data collection information. As a result of the decrease in the number of respondents, the burden hours decreased by 5,497 hours (from 94,905 to 89,408 hours). Based numbers derived from PECOS, the total number of respondents decreased by 21,991 (from 379,619 to 367,628).

Annual Cost to Federal Government: $0

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. No

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. Yes

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: Jamaa Hill 301 492-4190

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