Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 (CMS-4040)

Forms and Documents

Document Name	Status
Form CMS-4040SP Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 Form and Instruction	Modified
CMS-4040 - Supporting Statement A [rev 02-17-2017 by OSORA PRA].doc Supporting Statement A	2017-02-17
Justification - Use of SSNs 0938-0245 CMS-4040.pdf Supplementary Document	2017-02-17

IC Document Collections

IC ID	Document Title	Status
7901	Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0245	ICR Reference No: 201702-0938-004
Status: Historical Active	Previous ICR Reference No: 201309-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 (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: 05/12/2017
	Date Received in OIRA: 02/22/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2020	36 Months From Approved	05/31/2017
Responses	47,200	0	10,000
Time Burden (Hours)	11,800	0	2,500
Cost Burden (Dollars)	0	0	0

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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.

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

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 91175	12/16/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 11037	02/17/2017
Did the Agency receive public comments on this ICR? No

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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, CMS-4040SP	Petici?n Para Inscribirse En El Seguro Medico Suplementario ,   Request for Enrollment in Supplementary Medical Insurance

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	47,200	10,000	0	37,200	0	0
Annual Time Burden (Hours)	11,800	2,500	0	9,300	0	0
Annual Cost Burden (Dollars)	0	0	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 2017 iteration is an Extension that does not propose any program changes. However, based on better data we are adjusting our respondent estimate from 10,000 to 47,200, a change of 37,200. Our 15 minute per response estimate is unchanged.

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Annual Cost to Federal Government: $333,822

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/22/2017

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