Crosswalk

Revisions to Form CMS 18-F-5 (OMB 0938-0251) Application for Enrollment in Part A (Hospital Insurance)

The electronic mechanism was updated to add a data element that is currently approved under this package for the paper form and the other electronic mechanisms. There were no statutory or regulatory changes and the burden was not impacted.

Approved iClaim Screens	Proposed iClaim Screens	Reason for Change	Burden Effect
The currently approved iClaim screens under this package do not include questions pertaining to the special enrollment period (SEP) for international volunteers.	The proposed iClaim screens include questions related to the SEP for international volunteers. OMB has approved the use of iClaim for other SEPs under OMB # 0938-1426.	CMS seeks this change request to include the SEP for international volunteers data element under SSA’s iClaim. This change does not add any new questions or requests for information. It only adds the ability to use an electronic mechanism to enroll in Part A for individuals who were international volunteers. We don’t expect a change in burden, but will monitor enrollments and make adjustments during the next renewal process.	This change does not effect the burden.