CMS-18F5OMBsst2010

Supporting Statement for the CMS-18
Application for Hospital Insurance and
Supporting Regulations in 42 CFR §§ 406.6,
406.7, 406.10, 406.11 and 406.20
A.

BACKGROUND
Individuals who are entitled to social security or railroad retirement
board (RRB) benefits and those who are entitled to disability benefits
under social security or the RRB are automatically entitled to
Medicare Hospital Insurance (Part A) when they attain age 65 or
reach the 25th month of disability benefit entitlement. These
individuals do not file a separate application for Part A because the
application for social security or RRB benefits is also an application
for Part A.
Individuals who are not entitled to or eligible for RRB or SSA benefits
must file an application for Part A. This group includes individuals
who defer filing an application for monthly benefits, individuals who
are transitionally insured, government employees who pay only the
Hospital Insurance portion of the Federal Insurance Contributions Act
tax and individuals eligible for Premium Part A for the Working
Disabled.
The Application for Hospital Insurance-CMS-18F5 was designed to
capture all the information needed to make a determination of an
individual’s entitlement to Part A.

B.

JUSTIFICATION
1.

Need and Legal Basis
The Social Security Act at §226(a) (attachment 1), §227
(attachment 2), §1818 (attachment 3) and §1818A (attachment
4) and the Code of Federal Regulations at 42 CFR §406.10
(attachment 5), §406.11 (attachment 6) and §406.20
(attachment 7) outline the requirements for entitlement to
Medicare Hospital Insurance (Part A).
Federal regulations at 42 CFR §406.6 (attachment 8) specifies
the individuals who must file an application for Part A and those

who need not file an application for Part A. 42 CFR §406.7
(attachment 9) lists the CMS-18F5 as the application to be used
by individuals applying for Part A.
The form CMS-18F5 (attachment 10) and the Spanish version
the CMS-18F5 SP ( attachment 11) elicit the information that
the Social Security Administration (SSA) and the Centers for
Medicare & Medicaid Services (CMS) need to determine
entitlement to Part A and Supplementary Medical Insurance
(Part B).
2.

Information Users
The CMS-18F5 is used to establish entitlement to Part A and
enrollment in Part B for beneficiaries who must file an
application. The CMS-18F5 (and CMS-18F5 SP) is currently
approved under OMB No. 0938-0251.
The CMS-18 F5 is completed with assistance from a Social
Security Administration (SSA) field office claims representative
or field representative using information provided by the
applicant during an interview. The application follows the
application questions and requirements used by SSA on title II
applications. This is done not only for consistency purposes but
because certain title II and title XVIII insured status, relationship
and residency requirements must be met in order to qualify for
Part A (and Part B). The form is not completed by CMS staff.
The form contains seventeen questions that must be answered
to determine an individual’s eligibility for Medicare.
Items 1 – 3 request information to identify the applicant (name,
sex, date/place of birth and Social Security number (SSN).
Under §205 of the Social Security Act (the Act) the
Commissioner of SSA shall assign SSNs to all individuals,
including applicants for and recipients of benefits under any
federally funded program (e.g. Social Security, Supplemental
Security Income benefits and Medicare), aliens who are lawfully
present in the U.S. and children. The SSA uses the SSN as the

record identifier for applicants for or recipients of benefits under
title II and title XVIII of the Act. Because CMS does not obtain
or process applications for such benefits, it cannot assign an
alternative identifier.
Item 4 asks if the applicant has ever filed a application for social
security benefits, Part A or Part B. If the response is yes, the
individual is asked to provide the name and SSN under which
the application was filed. Since all records (title II and title XVIII)
in SSA are established and maintained by SSN, that number
must be requested to determine if entitlement previously
existed, currently exists or is pending.
Items 5 – 8 request information needed to determine insured
status.
In order to be entitled to free Part A an individual must be
insured, that is, s/he must have worked the required amount of
time under social security, the railroad retirement board (RRB)
or as a government employee or be the aged spouse of such an
individual who is at least 62 years of age. In this case, the
individual can use the insured status of a spouse to establish
entitlement to Part A (REF: §226(a)(1) of the Act). Under §205
of the Act, the Commissioner of Social Security shall establish
and maintain records of the amount of wages paid to each
individual and the amounts of self employment income. These
earnings are maintained under the worker’s SSN. The earnings
determine an individual’s (or his/her dependent’s) eligibility to
benefits and Part A.
Item 5 requests military information for periods before SSA
began crediting military service as earnings. SSA will credit
earnings for this period if they are needed to determine an
individual’s (and/or his/her dependent’s) eligibility to benefits
and Medicare (REF §229 of the Act).
Item 6 requests railroad work information to determine if insured
status is met based on that employment. RRB work credits can
also be added to work credits earned under social security to
meet the insured status requirement. This information is also

used to determine whether SSA or RRB has jurisdiction of the
Part A entitlement.
Item 7 requests information about work covered under a foreign
social security system. Foreign earnings can be used for
insured status for or to increase the amount of a title II benefit.
They cannot be used to determine insured status for free Part A
(REF: §233(c)(3).
Item 8 requests the individual’s own earning information.
Items 9 and 10 request citizenship and residency information
and are used in conjunction with item 18 when it is it is
determined that the individual does not meet the insured status
requirements for free Part A and is requesting enrollment in
premium Part A (REF: §1818 of the Act).
Item 11 and 13 request marital and spousal information and are
completed in conjunction with the request for information in
items 5 -8. SSA will use the spousal information and SSN to
determine if the spouse is insured and is age 62. As previously
stated, there are no alternative identifiers that SSA can use to
determine earnings information.
Item 11 requests information about the individual’s current
marriage (if any) and item 12 requests the same information
about prior marriages.
Item 13 asks if the applicant’s spouse was a railroad worker,
pensioner or annuitant to determine if insured status can be met
using the spouse's RRB earnings.
Item 14 asks if the applicant or his/her spouse was a civilian
employee with the Federal Government. This information is
needed to screen out individuals who may be precluded from
entitlement because they are covered under the Federal
Employees Health Benefits Act of 1959.
Item 15 solicits an enrollment request for premium Part A if the
individual is determined not to be eligible for free Part A.

Item 16 solicits an enrollment request for Medicare
supplementary medical insurance (Part B) when filed during an
applicable enrollment period.
Item 17 requests Federal Civil Service Retirement Act annuity
information about the applicant and their spouse. This is for the
purpose of deducting Part B premiums from an annuity paid by
the Office of Personnel Management (REF: §1840(d)(1).
3.

Use of Information Technology
The data collected for entitlement to benefits is not collected by
CMS but by SSA under an Interagency Agreement
The information from this application is collected in an online
environment and entered directly into the SSA Modernized
Claim System. The information is compared electronically to
the appropriate earnings information to determine insured
status and/or prior entitlement. Applications are processed and
directly input into the SSA Master Beneficiary Record. The data
is then passed to the CMS master record, the Enrollment
Database and a CMS health insurance record is established,
and where applicable a Medicare card is issued.
This collection requires an original signature under a fraud
statement.
This collection is not one of the applications currently
designated for use of electronic signature.
Additionally, applications are taken from individuals in situations
where the online system is not available. Even when a paper
application is taken, the data is subsequently entered in to the
online system to facilitate adjudication and data transfer. The
electronically collected data is adjudicated online and the data
is used to establish SSA and CMS master records. The SSA
and CMS systems communicate with each other through
electronic data exchange.

All data, whether collected on paper or online, is stored
electronically and transferred to the SSA and CMS master
records upon adjudication. The paper application and proofs of
entitlement are kept on file along with the award certificate
(which is also a printout from the online system) for a prescribed
length of time and then destroyed. The electronic data is
retained.
Although technology is used in the collection, processing and
storage of the data, the burden is not reduced by the use of
technology. The burden is in the interview to solicit and clarify
information that is collected electronically.
4.

Duplication of Efforts
Item 4 on the form requests information pertaining to previous
applications for benefits. It is elicited to ensure that a previous
claim has not already been filed and, if it has, to ensure that the
proper action will be taken by SSA. Even if the individual had
filed previously and entitlement has been denied or terminated,
the prior information must be updated to ensure proper
disposition of the new application.
If no duplication in filing has occurred, this information does not
duplicate any other effort and the information cannot be
obtained from any other source.

5.

Small Business
The use of this form does not involve small businesses.

6.

Less Frequent Collection
This information is collected once, at the time the individual files
for Hospital Insurance (Part A) of Medicare. If this information
is not collected, the applicant cannot establish entitlement to
Part A. Because there is a legal requirement to apply for
benefits either on paper or electronically, the burden cannot be
minimized.

7.

Special Circumstance
This collection is consistent with guidelines in 5 CFR 1320.6.
There are no special circumstances.

8.

Federal Register/Outside Consultation
The 60 day Federal Register notice was published on October 8, 2010
Vol. 75, No. 195, pg.62401 attached. No comments were received.
The gathering of this information is a necessary part of the
Medicare entitlement process. This form was developed in
1965 and has undergone only minor revisions since then.
Appropriate comments were solicited at that time. There have
been no problems associated with the use of this form or the
procedures established. Since the data is collected only once,
there is no need for ongoing consultations.

9.

Payments/Gifts to Respondents
There are no payments/gifts made to respondents.

10.

Confidentiality
The information collected is protected under provisions of the
Privacy Act. A copy of the information collected is provided to
the applicant.

11.

Sensitive Questions
There are no questions of a sensitive nature asked on this form.

12.

Burden Estimate
Approximately 50,000 respondents annually request enrollment
into Medicare on a CMS-18F5. The average interview and
completion time for the CMS-18F5 is 15 minutes based upon
actual experience. (The completion time is the same whether
the application is taken on paper or in an electronic

environment because the time is spent soliciting the information
rather than completing the form.)
The burden is computed as follows:
There are 50,000 respondents taking 15 minutes per response.
Using the multiplier provided in Part II of the Paperwork
Reduction Act Submission worksheet the total burden hours are
12,495.
While there may be some cost to respondents, individuals
completing this from can be of any age but most are 65 or older.
Thus there are individuals completing this form who are
working currently, may not be working currently or never
worked. There are no appropriate wage categories to use to
annualize any cost to the respondents for 15 minutes.
13.

Capital Costs
There are no additional costs. SSA is the record keeper and
the collection and storage of this data represents no additional
cost. It is part of their normal claims activity.

14.

Cost to the Federal Government
Printing Costs:
The printing cost associated with the CMS-18F5 is $2,053.
Processing Costs:
Collection of data and processing is done by SSA claims and
field representatives (average grade is GS 11, step 5) whose
annual salary, without locality pay (based upon current OPM
tables) is $27.31 per hour. Thus, 12,495 burden hours (see
item 12) multiplied by $27.31 per hour = $341,238.45
The total Federal cost is $343,291.45

15.

Program/Burden Changes
There were no changes or adjustments.

16.

Publication and Tabulation Data
This information is not published or tabulated.

17.

Expiration Dates
CMS would like an exemption from displaying the expiration
date as this form is used on a continuing basis. To include an
expiration date would result in CMS having to continually
destroy forms.

18.

Certification Statement
There are no exceptions to the certification statement.

C.

COLLECTION OF INFORMATION EMPLOYING STATISTICAL
METHODS
There have been no statistical methods employed in this collection.