View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0938-0251	ICR Reference No: 202102-0938-008
Status: Historical Active	Previous ICR Reference No: 201804-0938-022
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Application for Enrollment in Medicare Part A, Internet Claim (iClaim) Application Screen, Modernized Claims System and Consolidated Claim (CMS-18F5)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/26/2021
	Date Received in OIRA: 02/16/2021
Terms of Clearance: As CMS and SSA should continue working together to improve enrollment information collection. In doing so, CMS and SSA should also continue working with their OIRA desk officers to foreshadow future changes.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2024	36 Months From Approved	08/31/2021
Responses	1,394,264	0	51,000
Time Burden (Hours)	305,665	0	29,580
Cost Burden (Dollars)	0	0	0

Authorizing Statute(s): US Code: 42 USC 1935i-2 Name of Law: Hospital Insurance Benefits for Uninsured Elderly Individuals not Otherwise Eligible
   US Code: 42 USC 426 Name of Law: Entitlement to Hospital Insurance Benefits
   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

Citations for New Statutory Requirements: None

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion	Change Due to Adjustment in Estimate
Annual Number of Responses	1,394,264	51,000	1,393,568	-50,304
Annual Time Burden (Hours)	305,665	29,580	305,491	-29,406
Annual Cost Burden (Dollars)	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This significant increase is a result of improved data provided by SSA, in addition to the transfer of the information technology collection instruments from SSA to CMS. CMS will begin reporting for additional collection instruments, including the Internet Claim System (iClaim) and the Modernized Claims System (MCS) soon to be upgraded to the Consolidated Claims Experience (CCE). The hourly burden from the 2017 approved submission increased from 29,580 hours to 305,665 hours -- a change of 276,085.

Annual Cost to Federal Government: $4,441,248

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. Yes

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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