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OMB Control No: 0938-0245	ICR Reference No: 202305-0938-014
Status: Historical Active	Previous ICR Reference No: 202003-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Request for Enrollment in Supplementary Medical Insurance (SMI) and Supporting Regulations in 42 CFR 407.10, 407.11 and 408.40(a)(2) (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: 08/16/2023
	Date Received in OIRA: 05/31/2023
Terms of Clearance: Prior to the re-submission of the information collection (IC) “Request for Enrollment in Supplementary Medical Insurance (SMI) and Supporting Regulations in 42 CFR 407.10, 407.11 and 408.40(a)(2) (CMS-4040)” (0938-0245), CMS will assess linguistic preferences across the Medicare population and translate this IC into additional languages as appropriate in order to increase accessibility and reduce health disparities. It is the expectation that CMS will translate this form into more languages that English and Spanish but the number of additional languages will be based on the agency’s assessment of its populations needs but these languages could include Traditional or Simplified Chinese, Vietnamese, Korean, Tagalog, Arabic, French, and Russian. This request is supported by the principles and priorities set forth in the memorandum titled “Improving Access to Public Benefits Programs Through the Paperwork Reduction Act” (April 13, 2022), the Executive Order 13985 on “Advancing Racial Equity and Support for Underserved Communities Through the Federal Government” (January 20, 2021), and the culturally and linguistically appropriate services (CLAS) standards (https://thinkculturalhealth.hhs.gov/clas/what-is-clas).

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2024	36 Months From Approved	08/31/2023
Responses	42,011	0	29,663
Time Burden (Hours)	10,503	0	7,416
Cost Burden (Dollars)	0	0	0

Abstract: The form CMS 4040 is used to establish entitlement to Supplementary Medical Insurance (Part B) by individuals ineligible for Hospital Insurance (Part A) under Title XVIII of the Social Security Act. The CMS-4040SP is also included in this renewal.

Authorizing Statute(s): Statute at Large: 18 Stat. 1836
   US Code: 42 USC 1395o Name of Law: Every individual who-
   Statute at Large: 18 Stat. 1840

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:
	88 FR 13830	03/06/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 34502	05/30/2023
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40	CMS-4040

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	42,011	29,663	12,348
Annual Time Burden (Hours)	10,503	7,416	3,087
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 data provided an increase of 12,348 respondents, from the approved 2019 submission more accurate data provided by SSA. SSA processes the form on behalf of CMS. Previously, CMS estimated the burden based on less reliable, historical trends. The current data is relative to all beneficiaries who enrolled in Part B only in 2021.

Annual Cost to Federal Government: $324,955

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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