Application for Enrollment in Medicare - The Medical Insurance Program (CMS-40B)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-40B Application for Enrollment in Medicare Part B (Medical Insurance)	Form and Instruction	Modified	Available
Form CMS-40B (SP) Solicitud De Inscripcion En La Parte De Medicare (Seguro Medico)	Form and Instruction	Modified	Available
Form CMS-40B (SP) Application for Enrollment in Medicare Part B (Medical Insurance)	Form and Instruction	Modified	Repair queued
40-B Response to Comment.docx	Supplementary Document	Uploaded 2023-11-24	Repair queued
Crosswalk of Changes CMS 40B.pdf	Supplementary Document	Uploaded 2023-11-24	Repair queued
CMS-40B - Supporting Statement A clean.docx	Supporting Statement A	Uploaded 2023-11-29	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
209928	Application for Enrollment in Medicare Part B (Medical Insurance)	Form and Instruction	Modified	Application for Enrollment in Medicare Part B (Medical Insurance)
209928	Application for Enrollment in Medicare Part B (Medical Insurance)	Form and Instruction	Modified	Solicitud De Inscripcion En La Parte De Medicare (Seguro Medico)
209928	Application for Enrollment in Medicare Part B (Medical Insurance)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1230	ICR Reference No: 202311-0938-011
Status: Historical Active	Previous ICR Reference No: 202012-0938-016
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Application for Enrollment in Medicare - The Medical Insurance Program (CMS-40B)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/10/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/29/2023
Terms of Clearance: Prior to the re-submission of this information collection (IC), CMS will assess linguistic preferences across the respondent population and translate this IC into additional languages as appropriate in order to increase accessibility and reduce health disparities. It is the expectation that CMS will translate this form into more languages than English and Spanish, but the number of additional languages will be based on the agency’s assessment of population needs. These languages could include both Traditional and Simplified Chinese, Vietnamese, Korean, Tagalog, Arabic, French, and Russian. This request is supported by the principles and priorities set forth in the memorandum titled “Improving Access to Public Benefits Programs Through the Paperwork Reduction Act” (April 13, 2022), the Executive Order 13985 on “Advancing Racial Equity and Support for Underserved Communities Through the Federal Government” (January 20, 2021), Executive Order 13166, "Improving Access to Services for Persons with Limited English Proficiency" (August, 11, 2000) and the culturally and linguistically appropriate services (CLAS) standards.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2025	36 Months From Approved	12/31/2024
Responses	1,068,715	0	400,000
Time Burden (Hours)	265,288	0	100,000
Cost Burden (Dollars)	0	0	0

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Abstract: The Form CMS-40B is used to establish enrollment in Supplementary Medical Insurance (Part B). The information collected on the form is needed to determine an individual's eligibility for Medicare Part B.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1840
   Statute at Large: 18 Stat. 1836
  

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:
	88 FR 57461	08/23/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 82379	11/24/2023
Did the Agency receive public comments on this ICR? Yes

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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 Enrollment in Medicare Part B (Medical Insurance)	CMS-40B, CMS-40B (SP)	Solicitud De Inscripcion En La Parte De Medicare (Seguro Medico) ,   Application for Enrollment in Medicare Part B (Medical Insurance)

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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	1,068,715	400,000	0	668,715	0	0
Annual Time Burden (Hours)	265,288	100,000	0	165,288	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: The significant burden change is due to the estimated number of respondents increasing from 400,000 to 1,068,715 and CMS’ reliance on SSA’s improved data with consideration of the enrollment policies and processes which permit enrollment through 3 different enrollment mechanisms: paper form, online, and interview with SSA technician. The use of information technology section was updated to include the additional response methods.

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Annual Cost to Federal Government: $8,544,927

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? No

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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: 11/29/2023

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