Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13 (CMS-43)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-43 Application for Hospital Insurance Benefits for Individuals with End Stage Renal Disease	Form	Modified	Available
CMS-43 - Supporting Statement A - Passback CMS Response (rev 02-13-2018 by OSORA PRA).doc	Supporting Statement A	Uploaded 2018-02-13	Available
Justification - Use of SSNs 0938-0080 CMS-43.pdf	Supplementary Document	Uploaded 2017-07-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7835	Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13	Form	Modified	Application for Hospital Insurance Benefits for Individuals with End Stage Renal Disease

ICR Details

OMB Control No: 0938-0080	ICR Reference No: 201707-0938-008
Status: Historical Active	Previous ICR Reference No: 201311-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13 (CMS-43)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/13/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/19/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2021	36 Months From Approved
Responses	25,000	0	0
Time Burden (Hours)	10,400	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The CMS-43 form is used to establish entitlement to Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B) by individuals with End Stage Renal Disease (ESRD).

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Authorizing Statute(s): US Code: 42 USC 426-1 Name of Law: Special Provisions Relating to Coverage Under Medicare Program for End Stage Renal Disease
  

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:
	82 FR 14517	03/21/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 31609	07/07/2017
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13	CMS-43	Application for Hospital Insurance Benefits for Individuals with End Stage Renal Disease

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ICR Summary of Burden

table that charts list 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	25,000	0	0	0	-35,000	60,000
Annual Time Burden (Hours)	10,400	0	0	0	-14,560	24,960
Annual Cost Burden (Dollars)	0	0	0	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: We propose to adjust our respondent burden (from 60,000 respondents to 25,000 respondents) based on improved methods of estimating the number of respondents. The Medicare Beneficiary Database (MBD) provides more accurate data than was previously used in 2013. The data for the 12 month period of January-December 2016 was used to determine the annual number of responses. This information was used to determine that there was a significant decrease in responses compared to 2013. In this regard, our time estimate has decreased by -14,560 hours. We now estimate an annual burden of 10,400 hours.

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Annual Cost to Federal Government: $534,475

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? 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: 07/19/2017

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