CMS-40B - Supporting Statement

Supporting Statement Part A

Application for Enrollment in Medicare Part B (Medical Insurance)

CMS-40B, OMB 0938-1230

Background

In this 2025 iteration, CMS is requesting approval for a OMB Reinstatement with change approval type due to substantive changes to the CMS-40B form.

Medicare Part B is a voluntary program, financed from premium payments by enrollees, together with contributions from funds appropriated by the Federal government. The Social Security Act (the Act) at section 226(a) provides that individuals who are age 65 or older and eligible for, or entitled to, Social Security or Railroad Retirement Board (RRB) benefits shall be entitled to premium-free Part A upon filing an application for such benefits. Section 1836 of the Act permits individuals with Medicare premium-free Part A to enroll in Part B.

Form CMS-40B is used by individuals who want to enroll in Part B. Such individuals enroll in Medicare Part B during their initial enrollment period IEP; the general enrollment period (GEP), which occurs from January through March each year; or during certain special enrollment periods (SEP)

Form CMS-40B provides a standardized means to determine the eligibility criteria for enrollment in Part B, as outlined in law. Information that is collected on Form CMS-40B (and the Spanish version CMS-40B-SP) is used by the Social Security Administration (SSA) – the Centers for Medicare & Medicaid Services’ agent for processing Medicare enrollments.

In collaboration with CMS Office of Communications, the form has been redesigned to improve the user’s experience. This includes updating the form’s title to Request for Enrollment in Medicare Part B (Medical Insurance) from Application for Enrollment in Medicare Part B (Medical Insurance), reframing questions so that respondents can make clear enrollment choices. These changes will also allow technicians to enroll respondents more efficiently.

The form was updated to add the optional collection of email addresses. In response to SSA technician’s feedback, the form now includes a question that allows the applicant to select a Medicare start date. CMS’ Office of Communications provided feedback on the form design and the layout of the questions. The form was redesigned to give the applicant’s a more user-friendly experience. No additional changes were made and the burden was not impacted by the changes.

These substantive changes resulted in no substantial change to the burden.

A. Justification

1. Need and Legal Basis

Section 1836 of the Act and regulations at 42 CFR 407.10 provide the eligibility

requirements for enrollment in Part B. Under the regulations, individuals may enroll in Medicare Part B by signing a statement requesting Part B, if eligible for enrollment at that time. Individuals use the standardized Form CMS-40B to request enrollment.

The CMS-40B (and the CMS-40B-SP) collects the information that SSA needs to determine eligibility for and process enrollments into Part B.

2. Information Users

The CMS-40B provides the necessary information to determine eligibility and to process the beneficiary’s request for enrollment for Medicare Part B coverage. This form is only used for enrollment by beneficiaries who already have Part A, but not Part B.

Form CMS-40B is completed by the person with Medicare or occasionally by an SSA representative using information provided by the Medicare enrollee during an in-person interview. The form is owned by CMS, but not completed by CMS staff. SSA processes Medicare enrollments on behalf of CMS.

Collection of Information Instruments and Instruction/Guidance Documents

• Application for Enrollment in Medicare Part B (Medical Insurance)

The application form consists of nine items that are necessary to identify the enrollee and process the request.

Section 1- Basic Information

1. Medicare Number of the applicant including the Beneficiary Identification Code

2. Applicant’s name

3. Applicant’s full mailing address, including state and zip code and the applicant’s phone number including area code

4. Applicant’s phone number

5. Applicant’s email address

Section 2- Enrollment in Medicare Part B

1. Requests information about employer group health plan coverage. SSA uses this to determine eligibility for an SEP.

2. Requests information about international volunteer health coverage. SSA uses this to determine eligibility for an SEP.

3. Requests information about dates of employment and health coverage.

4. Asks if an employer, health insurance provider, or other entity asked or required the applicant to enroll in Part B?

Coverage Start Date

Applicants who are applying for Part B using the SEP based on employer group health plan coverage have the option to select the coverage start date.

3. Use of Information Technology

The data collected for entitlement to Part A and B is not collected by CMS but by SSA under an Interagency Agreement. The agencies’ relationship is governed by Title XVIII of the Social Security Act.

In addition to the paper application as described above, applicants may apply via interview with an SSA employee over the phone or at a field office or online. Approximately 16% of applicants for Medicare Part B use the online form.

Online Application:

Individuals can file an application for Part B online if they are enrolling using the special enrollment period (SEP) for individuals insured under an employer group health plan. 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.

In person or Telephonic Interview:

Individuals have the option of enrolling telephonically or via an in-person interview. SSA technicians conduct the interview and use an electronic system to input data collected from the applicant during the interview.

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.

Paper Form:

The form CMS-40B is available on the internet (https://www.cms.gov/cms40bapplication-enrollment-part-b).

Form CMS-40B-SP is also available on the internet (https://www.cms.gov/cms40bsolicitud-de-inscripcion-en-la-parte-b).

Individuals complete the form and submit it to SSA for processing. The information completed on the form is reviewed manually by SSA.

4. Duplication of Efforts

This information does not duplicate any other effort, as the person with Medicare must initiate the request for enrollment into Part B coverage. Use of this form is the initial request by the individual. Even if the individual previously had and dropped Medicare

Part B, the information must be updated to ensure proper disposition of the new request.

This information is not available from any other source.

5. Small Businesses

Small businesses are not affected by the collection of this information.

6. Less Frequent Collection

This information is collected only as needed, and only when an existing Medicare beneficiary requests to enroll in Part B. Each individual respondent uses the form one time when he or she submits the request to enroll in Part B. If this information is not collected, the individual cannot enroll in Part B. Since the statute permits enrollment and specific data is necessary to determine eligibility, the burden cannot be minimized.

7. Special Circumstances

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.

8. Federal Register Notice/Outside Consultation

Federal Register Notice

The 60-day Federal Register Notice published in the Federal Register (89 FR 86340) on 10/30/2024.

No comments were received during the 60-day comment period.

The 30-day Federal Register Notice published in the Federal Register (90 FR 13368) on 3/21/2025.

9. Payment/Gift to Respondents

There are no payments or gifts provided to respondents.

10. Confidentiality

This collection will be used solely by SSA for the purpose of determining a beneficiary’s eligibility Medicare Part B. Both CMS and SSA are responsible for ensuring that all personally identifiable information (PII) remains confidential.

The completed form is not provided to CMS, rather it is stored with SSA.

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 (Hours & Wages)

Respondent Burden Hours

Method of Completion	Number of Responde nts	Frequency of Response	Average Burden Per Response (minutes)	Estimated Annual Burden (hours)	Average Wait Time in Field Office (minutes)	Estimated Total Annual Burden (hours) for Wait Time)
Interview	947,637	1	15	236,909	24	379,055
Online	189,527	1	10	32,220	N/A
Paper Form	47,382	1	30	23,691	N/A
Totals	1,184,546			292,820

Wage Estimates

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.

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

We estimate that there are approximately 1,184,546 respondents annually requesting enrollment in Part B using this collection. The burden is computed as follows:

We estimate an annual burden of 292,820 hours at a cost of $6,767,070 (292,820 hrs x $

23.11/hr) or $5.71 per respondent ($6,767,070/1,184,546 respondents).

13. Capital Costs

There are no capital costs.

14. Cost to Federal Government

Method of collection	Number of respondents	Minutes to collect and input data	Burden Hours	Base hourly rate	Cost
Interviews	947,637	15	236,909	$33.73	$7,990,941
Online	189,527	10	32,220	$33.73	$1,086,781
Paper	47,382	30	23,691	$33.73	$ 799,097
Total Cost	1,184,546	55	292,820	$33.73	$9,876,819

To derive average costs, we used data from the Office of Personnel Management 2023

General Schedule (GS) Locality Pay Table for all salary estimates

(https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salarytables/24Tables/html/GS_h.aspx). We estimate that the average government employee at SSA to receive and record the collected data be a Grade 11, Step 5 (GS-11-5) – which we believe is the most appropriate level for a SSA representative to derive the costs to process this form.

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 $33.73 or $70,387 annually.

We estimate an annual burden of 292,820 hours at a cost of $9,876,819 (292,820 hours x $33.37/hr) or $8.33 per respondent ($9,876,819/ 1,184,546 respondents).

15. Changes to Burden

In this 2024 iteration, the estimated number of respondents increased from 1,068,715 to

1,184,546, an increase of 10.84%. The federal government burden hours increased from 265,288 hours to 292,820 hours, an increase of 10.38%. The increase in respondents is marginal.

Similar to the 2023 submission of this collection, CMS relied on data from the Enrollment and Eligibility Medicare Online (ELMO) system. The burden of federal government costs increased from the 2023 approved submission as a result of the factors mentioned above and the increase in wage for a federal employee GS 11-, step 5 from

32.21/hr in 2023 to $33.73 in 2024.

Updates have been made to the CMS-40B collection instrument per the Social Security Administration’s (SSA) request. The 2024 iteration of the form will allow applicants to choose their Medicare Part B coverage start date. Applicants can elect to have coverage begin the first day of the month they enroll, or the first day of any of the three months after they enroll. If they choose the latter option, they must write which month and year they want coverage to begin.

SSA has also requested that the form clarify that individuals must have continuous employer Group Health Plan (GHP) coverage to qualify for the Special Enrollment Period, and to give applicants the option to provide their email address on the form and receive emails from Social Security and Medicare about their benefits and coverage.

16. Publication/Tabulation Dates

This information is not published or tabulated.

16. Expiration Date

The form displays the expiration date next to the OMB control number.

16. Certification Statement

There are no exceptions to the certification statement.

19. Collection of Information Employing Statistical Methods

Not applicable. There are no statistical methods.

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