View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-0080	ICR Reference No: 202407-0938-001
Status: Active	Previous ICR Reference No: 202101-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Application for Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease and Supporting Statute and Regulations in 42 CFR 406.7 and 406.13 (CMS-43)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/20/2024
	Date Received in OIRA: 07/10/2024
Terms of Clearance: Prior to the re-submission of the information collection “Application for Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease and Supporting Statute and Regulations in 42 CFR 406.7 and 406.13 (CMS-43)” (0938-0829), the agency will evaluate the burden, usability, and clarity of the forms and appeals process.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2026	36 Months From Approved
Responses	45,200	0	0
Time Burden (Hours)	18,984	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	45,200	24,818	20,382
Annual Time Burden (Hours)	18,984	10,424	8,560
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: There are significant increases to the burden in this submission. First, the annual number of respondents increased from 25,000 to 45,200 and the average cost for each individual to complete the form increased to $22.26. This growth of the respondents has had an increase on collections annual total hourly burden.

Annual Cost to Federal Government: $1,083,179

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. 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? No

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

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