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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-40B Enrollment Screenshots	Form and Instruction	Modified	Available
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
CMS-40B - Supporting Statement.docx	Supporting Statement A	Uploaded 2025-06-03	Repair queued
CMS-40B - Supporting Statement.docx	Supporting Statement A	Uploaded 2025-03-21	Repair queued
Crosswalk of Changes CMS 40B_.docx	Supplementary Document	Uploaded 2025-06-03	Repair queued
Crosswalk of Changes CMS 40B_508.pdf	Supplementary Document	Uploaded 2025-01-23	Missing upstream

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	Enrollment Screenshots
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
209928	Application for Enrollment in Medicare Part B (Medical Insurance)	Instruction	Modified

ICR Details

OMB Control No: 0938-1230	ICR Reference No: 202501-0938-012
Status: Active	Previous ICR Reference No: 202311-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Application for Enrollment in Medicare Part B (Medical Insurance) (CMS-40B)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/08/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/28/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2028	36 Months From Approved
Responses	1,184,546	0	0
Time Burden (Hours)	292,820	0	0
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:
	89 FR 86340	10/30/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 13368	03/21/2025
Did the Agency receive public comments on this ICR? No

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

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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	1,184,546	0	0	0	115,831	1,068,715
Annual Time Burden (Hours)	292,820	0	0	0	27,532	265,288
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: In this 2024 iteration, the estimated number of respondents increased from 1,068,715 to 1,184,546, an increase of 10.84%. Similar to the 2023 submission of this collection, CMS relied on data from the Enrollment and Eligibility Medicare Online (ELMO) system.

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Annual Cost to Federal Government: $9,876,819

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: 03/28/2025

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