Crosswalk

Revisions to Form CMS-43 (OMB 0938-0080) Application for Part A (Hospital Insurance) and Part B (Medical Insurance)
For People with End-Stage Renal Disease
The current form is called Application for Hospital Insurance for Individuals with End-Stage Renal Disease. The new title,
Application for Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease, has been
updated to clarify that people with ESRD can use the form to apply for both Parts A and B. Additionally, there are changes to the
collection instrument—the prior form had 17 questions, and the new form has 7 sections. Each section has approximately 2-13
questions, but not every section will be applicable to each applicant. There were no statutory changes, and the burden was not
impacted.
Page Number

Original Form

Updated Form

Reason for Change

Page 1

Questions 1-4- Gather
basic enrollment
information (Name, sex,
DOB, citizenship status)

Introduction Page

The CMS-43 is being redesigned
to follow the format of the newer
Medicare Part A and B
enrollment forms, including the
CMS- 18-F-5 (OMB 0938-0251).

Questions 5-7- Gather
End-Stage renal disease
information
(Dialysis/kidney
transplant information)
Question 8- Provides
information on
Medicare Part B
premium deductions
from Social Security,
Railroad Benefits, or
Office of Personal
management benefits,
and the alternative
option for paying the
premium if a beneficiary

Explains who can use
the application, when it
can be used, evidence
needed to prove ESRD
diagnosis, how to
submit the application,
where to get help
completing the
application, and
information on how to
get the application in
another format (i.e.,
large print, braille, or
audio).

The current form does not
explain the form’s purpose and
who can use it.

Burden
Effect
N/A

does not receive such
benefits.
Page 2

Questions 8a-8bGathers information on
the applicant wants to
enroll in Medicare Part
B, and when they want
coverage to start.
Questions 9-12 Gather
information needed to
determine insured
status for Medicare
entitlement.

Page 3

Questions 13-17 Gather
information needed to
determine insured
status for Medicare
entitlement, including
employment
information, and marital
status.

When you can apply
for Part A (Hospital
Insurance) and Part B
(Medical Insurance)
Provide information to
applicant about when
they’re first eligible.
Lists special messages
with important
information about
enrolling in original
Medicare based on
ESRD and when
coverage will end.

This change is due to the
redesign. Newer enrollment
forms highlight when an
applicant can apply for Medicare
Parts A and B.

N/A

Section 1. Tell Us
About Yourself Gather
basic enrollment
information.

The current form asks the
applicant to list all employers for
the last year, self-employment,
and if it’s ok to contact the
employer for wage information
needed to process the claim. This
information is not necessary for
determining eligibility or
processing the claim.

N/A

Section 2. Tell Us
About Your Earnings
and Work History
Gather basic work and
earnings information.
Section 3. Tell Us
About Your Citizenship

It is sufficient to ask the applicant
what their earnings were last
year and what they anticipate
earning in the current year.

Gather basic citizenship
information.
Page 4

Remarks – 14 lines of
space for applicant to
add remarks.

Section 4. Tell Us
About Your Marital
Status
Gather information
Important Information - only if the applicant is
Explains when Medicare using their spouse or
coverage based on ESRD former spouse’s work
will end.
record or Social
Security/Railroad
Signature
Retirement Board
insured status to qualify
for Medicare.
Section 5: Tell Us
About Your Medical
History
Gather information
about dialysis and
transplant(s).
Section 6: Enrollment
in Part B Gather
information on whether
applicant wants to
enroll in Medicare Part
B and allows applicant
to chose from three
options for the first
month of entitlement.

The current form provides 14
lines for the applicant to add
remarks. The new form offers
space for remarks on Page 5 in
Section 7.
On the new form, information
about when coverage will end
has been moved to Page 2 as a
special message.

N/A

Page 5

Page 6

Privacy Notice

Section7: Remarks

PRA Disclosure

Section 8: Signature

N/A

Privacy Notice
PRA Disclosure

The redesigned form is one page
longer than the current form. The
signature section and remarks
have been moved to page 5.
The Privacy Notice/ PRA
Disclosure is the last page of the
form. Page 6 is the last page of
the form on the redesigned CMS43.

N/A

N/A