Supporting Statement A for Medicare Applications:
Application for Enrollment in Medicare Part A
Internet Claim (iClaim) Application Screen
Modernized Claims System and Consolidated Claim Experience Screens
Supporting Regulations in 42 CFR 406.6, 406.7, 406.10, 406.11 and 406.20
(CMS-18F5, OMB 0938-0251)
The Centers for Medicare and Medicaid Services (CMS) Form “Application for Hospital Insurance” supports sections 1818 and 1818A of the Social Security Act (the Act) and corresponding regulations at 42 CFR §§ 406.6 and 406.7.
Individuals who are entitled to retirement or disability benefits under Social Security Administration (SSA) or Railroad Retirement Board (RRB) benefits are automatically entitled to Medicare Hospital Insurance (Part A) when they attain age 65 or reach the 25th month of disability benefit entitlement. These individuals do not file a separate application for Part A because their application for Social Security or RRB benefits is also an application for Part A.
Individuals who are not entitled to or eligible for Social Security or RRB benefits must apply for Part A during their initial enrollment period (IEP), the general enrollment period (GEP), or, if they qualify, a special enrollment period (SEP). This group includes individuals who defer filing an application for monthly benefits, individuals who are transitionally insured, government employees who pay only the Hospital Insurance portion of the Federal Insurance Contributions Act (FICA) tax, and individuals eligible for Premium Part A for the Working Disabled.
The CMS-18-F-5 (Application for Enrollment in Part A (Hospital Insurance)) was designed to capture the information needed to determine an individual’s entitlement to Part A. Individuals complete the form and submit it to SSA to complete the enrollment. As an alternative, individuals can apply using the following electronic mechanisms:
Online at ssa.gov via SSA’s internet Claim System (iClaim)
Phone or in-office interview where responses are stored in the Modernized Claims System (MCS) and the Consolidated Claim Experience (CCE)
The electronic collection instruments are currently OMB approved under this package and also under SSA package 0960-0618. CMS has ownership of this collection only as it relates to Medicare, for the purposes of ICR review, PRA-compliance responsibilities, and ownership of the burden associated with the information collection. The operation of the information collection, including both electronic submission via iClaim as well as interview-based submission at field offices (which are ultimately recorded in MCS or the CCE), continues to be controlled by SSA.
This 2024 iteration is a re-instatement with changes to previously approved collection. The collection has expired due to program structural changes. These changes do not propose any program changes.
The Act at §226(a), §227, 1818 and §1818A and the Code of Federal Regulations at 42 CFR §406.10, §406.11 and §406.20 outline the requirements for entitlement to Medicare Hospital Insurance (Part A).
Federal regulation at 42 CFR §406.6 specifies the individuals who must file an application for Part A and those who need not file an application for Part A.
The form CMS-18F5 and the Spanish version the CMS-18F5 SP elicit the information that SSA and CMS need to determine entitlement to Part A and, optionally, Part B.
The CMS-18-F5 is used to establish entitlement to Part A and enrollment in Part B for claimants who must file an application.
The application follows the questions and requirements used by SSA on the electronic application. This is done not only for consistency purposes but because certain requirements under titles II and XVIII of the act must be met in order to qualify for Part A and Part B; including insured status, relationship and residency. The form is owned by CMS but is not utilized by CMS staff. SSA uses the form to collect information and make Part A and Part B entitlement determinations on behalf of CMS.
The form consists of seven questions that must be answered to determine an individual’s eligibility for Medicare.
Item 1 Tell Us About Yourself – Requests information to identify the applicant and obtain contact information. The identity information includes name, sex, date/place of birth and Social Security number (SSN) or Medicare Number if the applicant is already a Medicare recipient. The applicant’s SSN is requested to allow SSA to access their earnings systems to determine if the applicant is eligible for or entitled to premium-free Part A.
Item 2 Tell Us About Your Work History – Requests information needed to determine insured status. In order to be entitled to free Part A an individual must be insured, that is, they must have worked the required amount of time under social security, the railroad retirement board (RRB) or as a government employee as prescribed under §226(a)(1) of the Act). Under §205 of the Act, the Commissioner of Social Security shall establish and maintain records of the amount of wages paid to each individual and the amounts of self-employment income. These earnings are maintained under the worker’s SSN. The earnings determine an individual’s (or their dependent’s) eligibility to benefits and Medicare. We also request information about the individual’s current earnings and railroad work in order to determine if insured status is met based on recent employment that may not have posted on the individual’s earnings record. RRB work credits can also be added to work credits earned under social security to meet the insured status requirement. This information is also used to determine whether SSA or RRB has jurisdiction of the Part A entitlement.
Item 3 Tell us About Your Citizenship – Requests citizenship, lawful presence and residency information and is used to determine eligibility to Premium-HI when the individual does not meet the insured status requirements for free Part A and is requesting enrollment in premium Part A (REF: §1818 of the Act).
Item 4 Tell Us About Your Marital Status – Requests marital and spousal information and is completed in conjunction with the request for information in item 2. When individuals are not insured on their own work record, SSA will use the spousal information and SSN to determine if individuals are eligible for free Part A based on their spouses’ earnings record. As previously stated, there are no alternative identifiers that SSA can use to determine earnings information.
Item Enrollment in Premium Part A and Part B – Solicits an enrollment request for premium Part A if the individual is determined not to be eligible for free Part A. Provides the option to sign up for Part B.
Item 6 Tell Us About Your Current or Prior Health Coverage and Benefits – Requests information about receipt of Medicaid. SSA uses this information in conjunction with information collected in item 2 to determine if individuals are eligible for the State to pay their Part B premium. Also request information about prior and current health care coverage. SSA uses this information to determine the start date of Part B and surcharge amount, if any, when individuals are requesting Part B during the Special Enrollment Period (SEP). This item also requests Federal Civil Service Retirement Act annuity information about the applicant and/or their spouse. This is for the purpose of deducting Part B premiums from an annuity paid by the Office of Personnel Management. (REF: §1840(d)(1) of the Act)
Item 7 Sign Your Application - Requests information to determine if the individual completing and signing the application has the authority to sign the application when filing for someone other than themselves.
The data collected for entitlement to Part A and B is not collected by CMS but by SSA under an Interagency Agreement. In addition to the paper application as described above, applicants may apply online or via interview with an SSA employee over the phone or at a field. CMS seeks to transfer this collection from SSA to CMS for the purposes of ownership of the responsibility of PRA compliance, but SSA will continue to operate both the electronic and non-electronic means of collecting this information.
Internet Claim (iClaim) Application:
The public can file an Application for Hospital Insurance online if they are filing for Medicare based on their own work record. They access tiClaim via SSA’s website. The responses applicants input into iClaim determine the screens/questions they will receive, ensuring they only respond to relevant questions. After completing the online application, claimants or their third-party representatives can submit it electronically to SSA, avoiding the need to visit an SSA office. iClaim is more convenient for users and reduces their application completion time by eliminating the need for an office visit. This also saves time and resources for SSA.
The iClaim system can be found online at https://secure.ssa.gov/iClaim/rib. SSA POMS regarding the iClaim system, application, and process is available at https://secure.ssa.gov/poms.nsf/lnx/0200204020 .
Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE)):
MCS is an electronic system that technicians use to input data collected from the applicant during an in-person interview. Information collected with the paper form CMS-18-F5 or iClaim is also entered into MCS. All data, whether collected on paper or online, is stored electronically and transferred to the SSA and CMS master records upon adjudication. The electronic data is retained.
Although technology is used in the collection, processing and storage of the data, the burden is not reduced by the use of technology. The burden is in the interview to solicit and clarify information that is collected for the application.
Duplication of Efforts
There is no duplication of effort.
Small Business
The use of this form does not involve small businesses.
This information is collected once, at the time the individual files for Hospital Insurance (Part A) of Medicare and Part B. If this information is not collected, the applicant cannot establish entitlement to Part A. Because there is a legal requirement to apply for benefits either on paper or electronically, the burden cannot be minimized.
7. Special Circumstance
There are no special circumstances that would require an information collection to be conducted in a manner that requires respondents to:
Report information to the agency more often than quarterly;
Prepare a written response to a collection of information in fewer than 30 days after
receipt of it;
Submit more than an original and two copies of any document;
Retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;
Collect data in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study,
Use a statistical data classification that has not been reviewed and approved by OMB;
Include a pledge of confidentiality that is not supported by authority established in statute or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or
Submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.
The 60-day Federal Register notice published in the Federal Register (89 FR 23598) on 04/04/2024.
The collection received 1 comment during the 60-day comment period. The public posted a suggestion for CMS to change the question on the form pertaining to name at birth. We have taken the comment into consideration and updated the question to ask for the individuals name as it appears on their birth certificate. This change and response can be located in the supplemental documents attached to the package.
The 30-day Federal Register notice published in the Federal Register (89 FR 70191) on 8/29/2024.
The gathering of this information is a necessary part of the Medicare entitlement process. This form was revised in 2023. Appropriate comments were solicited at that time. There have been no problems associated with the use of this form or the procedures established. CMS continues to consult with SSA to ensure that the enrollment mechanisms are effective.
9. Payments/Gifts to Respondents
There are no payments/gifts made to respondents. This form is required to enroll in Medicare, if an individual is not auto-enrolled.
The information collected is protected under provisions of the Privacy Act. A copy of the information collected is provided to the applicant. System of Records Notice (SORN) that apply to Medicare claims:
60-0089 - Claims Folders System,
60-0090 - SSA’s Master Beneficiary Record (MBR),
60-0268 – Medicare Part B Buy-In Information System,
60-0310 Medicare Savings Programs Information System, and
60-0321 Medicare Database (MDB) File
11. Sensitive Questions
There are no sensitive questions associated with this collection. Specifically, the collection does not solicit questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.
12. Burden Estimate
Wages
To derive average costs for individuals, we used data from the U.S. Bureau of Labor Statistics’ May 2023 National Occupational Employment and Wage Estimates for our salary estimate (www.bls.gov/oes/current/oes_nat.htm). We believe that the burden will be addressed under All Occupations (occupation code 00-0000) at $23.11/hr since the group of individual respondents varies widely from working and nonworking individuals and by respondent age, location, years of employment, and educational attainment, etc.
We are not adjusting this figure for fringe benefits and overhead since the individuals’ activities would occur outside the scope of their employment.
Burden Estimates
The burden is computed as follows:
We estimate an annual burden of 400,493 hours (0.25 hour x 1,601,967respondents) at a cost of $9,255,393(400,493 hrs x $23.11/hr) or $5.78 per respondent ($9,255,393/1,601,967 respondents).
Method of Completion |
Number of Respondents |
Frequency of Response |
Average Burden Per Response (minutes) |
Estimated Annual Burden (hours) |
18-F-5 |
7,499 |
1 |
15 |
1,875 |
iClaim |
1,134,262 |
1 |
15 |
283,566 |
Interview/MCS |
460,206 |
1 |
15 |
115,052 |
Totals |
1,601,967 |
|
|
400,493 |
Information Collection/Reporting Instruments and Instruction/Guidance Documents:
Application for Enrollment in Medicare Part A
iClaim
MCS/CCE
There are no additional costs. SSA is the record keeper and the collection and storage of this data represents no additional cost. It is part of their normal claims activity.
14. Cost to the Federal Government
We estimate it will take the federal government employee 15 minutes (.25 hr) to review and record the collected data.
It is calculated that the burden hours for 1,601,967 responses to be reviewed and recorded in 15 minutes per response to be 400,493 total hours ((1,601,967 x 0.25(15 minutes)).
To derive average costs, we used data from Office of Personnel Management (OPM) 2024 General Schedule (GS) Locality Pay Table for all salary estimates (Pay & Leave : Salaries & Wages - OPM.gov). We estimate that the average government employee at SSA to conduct the interview is a GS 11 step 5. As the processing of this form occurs at the national level and not just one geographic location, we estimated the salary using the national base general schedule. Such an hourly wage is $70,387 or 33.73/hr. Therefore the total cost to the government to complete the annual volume of responses is $13,508,629 (400,493 hours x $33.73/hr).
The burden from CMS’s 2021 approved submission increased in cost from $4,441,258 to $13,508,629 for federal government costs – a change of $9,067,371. The hourly burden from the 2021 approved submission increased from 146,673 hours to 400,493 hours -- a change of 253,820. This change in burden is due to the increase in respondents and an increase in the federal employee’s wages. The number of respondents newly enrolling in Medicare can vary due to the number of individuals that become eligible yearly.
This increase is a result of updating the estimated time and costs for data reporting.
Publication and Tabulation Data
This information is not published or tabulated.
Expiration Dates
CMS displays the expiration date in the top right corner.
Certification Statement
There are no exceptions to the certification statement.
B. COLLECTION OF INFORMATION EMPLOYING STATISTICAL
There have been no statistical methods employed in this collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement for the Application for Hospital Insurance |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2024-09-06 |