OMB-CMS Q&A - February 2009

February 2009

Note to: Bonnie Harkless

Office of Strategic Operations and Regulatory Affairs

Subject: OMB Questions: 0938-0245: Request for Enrollment in Supplementary Medical Insurance (CMS-4040)

OMB asked the following questions about the form associated with Request for Enrollment in Supplementary Medical Insurance.  We have reorganized the questions in order to respond more effectively.

OMB Questions:

Question 2: Please correct the typo in the sentence below the Privacy Act notice – “informatino” should be “information.”

Question 4:  Item 6(a) – please delete the extra parenthesis at the beginning of the text under the question.

Question 9:  Regarding the witness mailing address – please include some space for city and state

Response: We have made the corrections.

Question 8:  Regarding the signature of applicant section – please change the “Name of Country” box to remove “(if any).”

Response: The “Name of Country” box should be “Name of County”. We have made the correction.

Question 1:  Regarding the Privacy Act notice, please take another look at this.  It is long, and contains typos.  Can CMS make this more readable for the average person?

Response: We believe that the privacy statement as written, meets the requirements of the Privacy Act of 1974. We also believe that the statement is readable and understandable. However, we have forwarded the privacy statement and your request to the Division of Privacy Compliance and the Office of E-Health Standards and Services for guidance.

CMS Follow-up: The Division of Privacy Compliance submitted the text below to revise the current privacy notice on form CMS-4040.

PRIVACY ACT NOTICE: SSA is authorized to collect the information on this form under sections 1836, 1840, and 1872 of the Social Security Act. Although the information is voluntarily, failure to provide all or part of the information requested could cause a delay on your application for enrollment or could be cause for denial of Medicare Part B benefits.  Information may be disclosed: 1) to enable a third party or another Federal agency to assist in establishing rights to Social Security benefits and/or hospital or medical insurance coverage; 2) to comply with Federal laws requiring the release of agency records; and 3) to facilitate statistical research and audit activities required by Social Security and CMS programs. In addition, verification of the information may be used in accordance with the computer matching provisions of the Privacy Act of 1974, as amended.

Question 3:  Item 4(a) – how likely is it that respondents will know which laws are administered by OPM?  Is there another way to phrase this?

Response: Extremely likely. This question is for those Federal employees who are entitled to (currently receiving) a Federal annuity. Generally, these individuals are not eligible for benefits under the social security system.

Question 7:  What do respondents use the “remarks” section for on this form?

Response: This section is used to provide the addresses at which the individual resided if more space is needed. (Refer to question #6.)

The responses to the following questions must be prefaced with the information below. The CMS-4040 is an initial application for Supplementary Medical Insurance (Part B) under the Medicare program. All applications for Medicare must be filed at the Social Security Administration. They cannot be filed at CMS. Once SSA processes the application, Medicare, demographic and other pertinent data is transmitted to CMS. The responses, therefore describe what actions are taken at SSA and how CMS reacts to the Medicare data that is sent to us from SSA.

Question 5: Item 6(b) – what does CMS do if the response is “No”?

Response: If the individual has not been “lawfully admitted for permanent residence” s/he is not eligible for Medicare Part B. SSA will deny the application.

Question 6:  Item 6(c) – what does CMS do with this address information?

Response: The address data that SSA transmits to CMS is used as the address of record. This is the address where the Medicare card, MSN and other correspondence is sent to the individual.

OMB follow-up: (regarding item 6(c)) – the response suggests that CMS only uses the most recent address.  Is this the case?

Response:  Yes, CMS only uses the current address for the reasons stated in our prior response.  The CMS-4040 requests the address for the last five years to determine if the individual filing the application meets the requirements of §1836(2) of the Social Security Act: the individual who is not a U.S. citizen must have resided in the U.S continuously for the 5 years immediately preceding the month the application is filed.  SSA must have this information in order to determine if the individual is eligible to enroll in Part B.

Question 10:   Is a copy of proof of age required along with this form?

Response: The individual must submit proof of age. However, it need not be submitted with form CMS-4040.

Question 11:  Is the form ever mailed in by respondents (rather than having in-person assistance)?

Response: No.

If you have any questions or require additional information please contact me at extension 48882 or via email at [email protected].

Margaret Jefferson

Medicare Enrollment and Appeals Group