View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-0245	ICR Reference No: 202003-0938-015
Status: Historical Active	Previous ICR Reference No: 201702-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 (CMS-4040)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/30/2020
	Date Received in OIRA: 03/24/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2023	36 Months From Approved	06/30/2020
Responses	29,663	0	47,200
Time Burden (Hours)	7,416	0	11,800
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	29,663	47,200	-17,537
Annual Time Burden (Hours)	7,416	11,800	-4,384
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: Burden estimates have decreased due to improved methods to approximate number of respondents using the Medicare Beneficiary Database (MBD). The data provided a decrease of 17,537 respondents, a significant decrease from the 2016 (47,200) approved submission and has been updated to 29,663 applicants who use Form CMS-4040.

Annual Cost to Federal Government: $218,465

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. 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

Agency Contact: Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov

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