Crosswalk

Revisions to Form CMS 18-F-5 Application for Hospital Insurance
The form was updated to include instructions and to provide clarity. There were no statutory or regulatory changes. The form changes
did not affect the burden.
Changes

Question

Updated Form

Original Form

Instructions Page
• Who can use this
application?
• When do you use this
application?
• What information do
you need to complete
this application?
• What’s next?
• How do I get help with
this application?
• HSA
• Part A reminder

Page 1

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Additional Information Premium
Part A and Part B

Page 2

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Applicant Personal Information

Page 3, Question 1 Tell Us
About Yourself

Page 1
1 a. Name
1b. Name at Birth

Reason for Change

Burden
Effect
An instructions page was created to N/A
provide applicants with additional
information about the forms
intended audience, when the form
should be used, what information
is needed to complete the form,
and what the next steps are.

The additional information page
was created to provide applicants
with key information about
enrollment periods and potential
enrollment penalties.
This section was updated to
remove questions related to public
or religious birth records before

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Work History

1a. Social Security
Number
1b. Your Name
1c. Name at Birth
1d. Sex
1e. Date of Birth
1f. State or Country of
Birth
1g. Mailing Address
1h. Address of permanent
residence
1i. Phone Number

1c. Sex
2. Social Security
Number
3a. Date of Birth
3b. State or foreign
country of birth
3c. Was a public record
of your birth made
before you were age 5?
3d. Was a religious
record of your birth
made before you were
5?
4 a. Have you (or
someone on your
behalf) ever filed an
application for social
security benefits, a
period of disability
under social security
supplemental security
income, or hospital
insurance under
Medicare?
4b. Enter the name of
person on whose social
security record you filed
other application?
4c. Enter social security
number of person
named in (b)

age 5 (questions 3c and 3d).
Removed questions related to
previous application filings
(questions 4a-c).

Page 3, Question 2

Pages 1-2 Questions 5-8

Removed questions about military
status (questions 5a-c), and work

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Citizenship

2a. How much were your
total earnings last year?
2b. How much do you
expect your total earnings
to be this year?
2c. Did you work in the
railroad industry after
January 1, 1937?

5a. Were you active in
outside of the U.S. (questions 7athe military or National
b).
Guard active duty or
active duty training after
September 7, 1939?
5b. Enter dates of
service.
5c. Have you ever been
(or will you be) eligible
for monthly benefit
from a military civilian
federal agency?
6. Did you work in the
railroad industry any
time on or after January
1, 1937?
7a. Have you ever
engaged in work that
was covered under the
social security system of
a country other than the
United States?
7b. List countries
8a. How much were
your total earnings last
year?
8b. How much do you
expect your total
earnings to be this year?

Page 3, Question 3
3a. Are you a United
States Citizen?

Page 2 Questions 9-10
9. Are you a resident of
the United States?

Added questions about permanent
residence in the U.S. Also
rephrased questions about
citizenship and lawful presence.

Marital Status

3b. Are you lawfully
present in the U.S.?
3c. When did you become
lawfully present in the
U.S.?
3d. Are you currently a
resident of the U.S.?
3e. When did you
become a resident of the
U.S.?
3f. Have you reside in the
U.S. without a break for
the past 5 years?
3g. Enter where you lived
for the last 5 years and
the dates you lived there.
3h. Have you been
outside the U.S. in the
last 5 years?
Page 3 Question 4
4a. Are you currently
married?
4b. Spouse’s Name
4c. Spouses Date of Birth
4d. Spouses Social
Security Number
4e. Date of Marriage
4f. If not married now,
did you have a former
marriage that lasted 10 or
more years OR ended in
death?
4g. Name of former
spouse?

10a. Are you a citizen of
the United States?
10b. Are you lawfully
admitted for permanent
residence in the United
States?
C. Enter information
requested about place
of residence in the last 5
years.

Removed requirement to provide
addresses to show 5 years of
residency.

Page 2, Questions 11-13
11. Are you currently
married?
To who married? When?
Spouse’s date of birth
(or age)? Spouses Social
Security Number?
12. If you had a previous
marriage and your
spouse died, OR if you
had a previous marriage
which lasted 10 or more
years, give the following
information. To who
married? When?

Changed the format of the
questions to fit the scope of the
new form. Deleted the question
about spouse’s railroad work
(question 13). Relocated the
questions related to civilian
government employment
(questions 14 a-d).

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4h. Former spouse’s date
of birth?
4i. Former spouse’s social
security number?
4j. Date of former
marriage?
4k. Date former marriage
ended?
4l. Date of former
spouse’s death, if
deceased?
4m. Do you have another
marriage that lasted 10
years or ended in death?

Spouse’s date of birth
(or age)? Spouses Social
Security Number? If
spouse deceased, give
date of death.
13. Is or was your
spouse a railroad
worker, railroad
retirement pensioner, or
a railroad retirement
annuitant?
14a. Were you or your
spouse a civilian
employee of the Federal
Government after June
1960?
14b. Are you or your
spouse now covered
under a medical
insurance plan provided
by the Federal
Employees Health
Benefits Act of 1959?
14c. Are you and your
spouse barred from
coverage under the
above Act because your
Federal employment, or
your spouse’s was not
long enough?
14d. Were either you or
your spouse an
employee of the Federal

Government after
February 15, 1965?
Enrollment in premium Part A
and Part B
Prior healthcare coverage

Page 4 Items 5-6
5a. If you have to pay a
premium for Part A, do
you still want to get Part
A?
5b. Do you want to sign
up for Part B?
6a. Do you have
Medicaid?
6b. Do you currently have
(or did you have)
coverage through an
employer or union group
health plan?
6c. Are you currently (or
were you) an
international volunteer
for a non-profit
organization and have or
had health coverage
provided to you?
6d. Enter dates of
employment (or
volunteer work) and
health coverage
6e. Are you or your
spouse currently getting
retirement benefits from
the Office of Personnel
Management (OPM)

Page 3 question 15,
Page 4 questions 16-17
15. If you are found to
be otherwise ineligible
for hospital insurance
under Medicare, do you
wish to enroll for
hospital insurance on a
monthly premium basis
(in addition to the
monthly premium for
supplementary medical
insurance)?
16. Do you wish to
enroll for Supplemental
Medical Insurance?
17. Are you or your
spouse receiving an
annuity under the
Federal Civil Service Act
or other law
administered by the
Office of Personnel
Management? Enter
your number. Enter your
spouse’s number.
If you entered your
spouse’s number, is he
(she) enrolled for
supplementary medical

Changed the format of the
questions to fit the scope of the
new form. Added questions in
reference to international
volunteer health coverage.

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Step by step instructions

6f. Your OPM retirement
claim number
6g. Your spouse’s OPM
retirement claim number
6h. Do you want to have
your Part B premiums
deducted from your
spouse’s retirement
benefits?
Pages 6-7

insurance under social
security?

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