Supporting Statement A

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Supporting Statement - Part A
Application for Medicare Part A (Hospital Insurance) and Part B (Medical Insurance)
for People with End-Stage Renal Disease
CMS-43, OMB 0938-0080

Notes: The title of our active collection is “Application for Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease.” This 2026 iteration proposes to revise the title as indicated above.

Supporting regulations can be found in 42 CFR 406.7 and 406.13.

The contents of this Supporting Statement and the associated attachments have been reviewed to ensure that they are consistent with the Trump administration’s policies, goals, and objectives.

Background

Form CMS-43 supports section 226A(a) of the Social Security Act (the Act) and corresponding regulations at 42 CFR 406.7(c)(3) and 406.13.

Individuals with End-Stage Renal Disease (ESRD) can apply for Medicare benefits and obtain premium-free Part A if they meet certain criteria outlined in statute. Sections 226A of the Act authorizes entitlement for Medicare Hospital Insurance (Part A) if the individual with ESRD files an application for benefits and meets the requisite contributions through one’s own employment or the employment of a related individual to meet the statutory definition of a “currently insured” individual outlined in section 214 of the Act.  Further, for individuals who meet the requirements for premium-free Part A entitlement, Medicare coverage starts based on the dates in which the individual started dialysis treatment or had a kidney transplant.  These statutory provisions are codified at 42 CFR 406.7(c)(3) and 407.13. 

The requirements in law for Medicare Part A entitlement differ from the criteria on the basis of age or disability.  As such, the existing applications for Medicare are not sufficient to capture the information needed to determine Medicare entitlement under the ESRD provisions of the law.  Form CMS-43 was designed specifically to capture all the information necessary to determine eligibility for Medicare entitlement and process the proper coverage start date. 

Form CMS-43 provides a standardized means to determine the eligibility criteria for entitlement to Medicare Part A, as outlined in law.  Information that is collected on Form CMS-43 is used by the Social Security Administration (SSA) – the Centers for Medicare & Medicaid Services’ (CMS) agent for processing Medicare entitlements.

On July 4, 2025, Public Law 119-21, the “Working Families Tax Cut” (WFTC) legislation was enacted. Section 71201 of the WFTC legislation amended Title XVIII of the Act (42 U.S.C. 1395 et seq.) (the Act) to add a new section 1899C, which provides that, subject to section 1899C(b) of the Act, an individual may be entitled to, or enrolled for, Medicare benefits only if the individual is in one of the following four groups: (1) a citizen or national of the United States (U.S.); (2) an alien who is lawfully admitted for permanent residence under the Immigration and Nationality Act (i.e. is a lawful permanent resident (LPR)); (3) an alien who has been granted the status of Cuban and Haitian entrant (CHE); or (4) an individual who lawfully resides in the U.S. in accordance with a Compact of Free Association (COFA migrant).

The changes proposed in this 2026 collection of information request are associated with our July 16, 2026 (91 FR 43842) CY 2027 Physician Fee Schedule NPRM (CMS-1848-P, RIN 0938-AV82) and with section 1899C of the Act.

While neither of the two have any impact on our currently approved (active) burden estimates, we are proposing to update our Medicare initial enrollment forms to expand the response options to include specific types of citizenship and alien status data elements to support Medicare Part A enrollment eligibility determinations. 

A.	Justification

1.	Need and Legal Basis

Section 226A of the Act provides that certain individuals diagnosed with ESRD may apply and become entitled to Medicare premium-free Part A.  To be eligible for Medicare Part A entitlement, individuals must: 

    • be diagnosed with ESRD; 
    • be fully or currently insured under the Social Security program (as outlined in section 214 of the Act), be entitled to Social Security benefits, or are the spouse or dependent child of a person who is insured or entitled to Social Security benefits;
    • file an application for Medicare benefits; and 
    • has satisfied the requisite waiting period based on when dialysis started or a transplant occurred.

2.	Information Users

The CMS-43 is used (in conjunction with the CMS-2728 (End Stage Renal Disease Medical Evidence Report), OMB control number 0938-0046) to establish entitlement to Medicare Part A and enrollment in Medicare Part B for individuals with ESRD.  Form CMS-43 is only used for initial applications for Medicare by individuals diagnosed with ESRD. Form CMS-2728 provides medical documentation that the individual has ESRD, and it accompanies Form CMS-43.

Form CMS-43 is completed by the person applying for Medicare or by an SSA representative using information provided by the Medicare enrollee during an in-person interview. Most of the forms are completed by an SSA representative on behalf of the individual applying for Medicare benefits.  The form is owned by CMS but not completed by CMS staff.  

3.	Use of Information Technology

The paper application is available on the internet at https://www.cms.gov/medicare/cms-forms/cms-forms/cms-forms-items/cms017342; it is also available by contacting SSA. 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 via interview with an in person or telephonically with an SSA employee. 

Interview/SSA Claim System (MCS/POS/MACADE): 
The SSA claim system is an electronic system that technicians use to input data collected from the applicant during an in-person 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 by both CMS and SSA.  

4.	Duplication of Efforts

Generally, there is no duplication of effort associated with this information collection, as use of this form represents the individual’s initial request for Medicare benefits.  Even in cases where an individual previously applied and entitlement was denied or later terminated; the information must be resubmitted and updated to ensure proper adjudication of the new application.  If no prior filing has occurred, the information cannot be obtained from any other source and does not duplicate any existing data collection.

The application is necessary because the individual must actively initiate enrollment into Part A and/or Part B, either by submitting the form or contacting SSA telephonically, making this the first request for enrollment.  As such, the information collected is not available from any other source and cannot be obtained without direct action from the individual.

5.	Small Business

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 individual applies for Medicare entitlement on the basis of ESRD.  Each individual respondent uses the form one time when they submit the request to enroll in Part A and/or Part B.  

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 secrets, or other confidential information unless the agency demonstrates that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.

8.	Federal Register/Outside Consultations

Serving as the 60-day notice, the CY 2027 PFS proposed rule (CMS-1848-P, RIN 0938-AV82) filed for public inspection on July 14 and published in the Federal Register on July 16, 2026 (91 FR 43842). Comments must be received by September 14, 2026.

9.	Payments/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 an individual’s eligibility for Medicare entitlement on the basis of ESRD.  The completed form is not provided to CMS and is stored by SSA. CMS does not review or store the application and data within it.   
 
Once SSA approves the Medicare entitlement, they will send CMS data so that we can establish the person on the Medicare rolls.  Personally Identifiable Information (PII), which includes the entitlement reason as being on the basis of ESRD, is stored at CMS.  The SSA Information Exchange Agreement No. 10042/CMS Information Exchange Agreement No. 2017-39 governs the exchange of information between SSA and CMS.

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 Estimates

Wage Data

We believe that the cost for beneficiaries undertaking administrative and other tasks on their own time is a post-tax wage of $24.05/hr.

The Valuing Time in U.S. Department of Health and Human Services Regulatory Impact Analyses: Conceptual Framework and Best Practices1 identifies the approach for valuing time when individuals undertake activities on their own time. To derive the costs for beneficiaries, we used a measurement of the usual weekly earnings of wage and salary workers of $1,1592 for 2024 and then divided by 40 hours to calculate an hourly pre-tax wage rate of $28.98/hr. This rate is adjusted downwards by an estimate of the effective tax rate for median income households of about 17 percent or $4.93/hr ($28.98/hr  x  0.17), resulting in the post-tax hourly wage rate of $24.05/hr ($28.98/hr - $4.93/hr). 

We are not adjusting this figure for fringe benefits and other indirect costs since the individuals’ activities would occur outside the scope of their employment.  
Burden Estimates

There are approximately 45,200 respondents annually who apply for Medicare on the basis of ESRD.  The data represents the most current information available, based on Medicare Part A entitlements on the basis of ESRD from January-December 2023, via the CMS Medicare Beneficiary Database (MBD).  Based on the information requested for completion by the applicant on the form, we estimate that it takes an applicant on average 25 minutes (or 0.42 hr) to complete.  In aggregate we estimate an annual burden of 18,984 hours (45,200 respondents x 0.42 hr) at a cost of $ 456,565 (18,984 hr x $24.05/hr) or $10.10 per beneficiary ($456,565/45,200 respondents). 

Number of applications 
Time per Response 
Total Time (hr) 
Labor cost
Total cost 
Cost per respondent 
45,200 
0.42 hr (25 min)
18,984
$24.05/hr
$456,565
$10.10

SSA is unable to share Calendar Year (CY) 2025 enrollment numbers with CMS. As a result, CMS will use the 2023 enrollment number of 45,200 for burden estimation purposes.  The CY 2023 enrollment figures for the CMS-43 form package represent the only data to date that has been formally provided by SSA.  It is worth noting that for prior Paperwork Reduction Act (PRA) submissions associated with this form package, CMS did not rely on SSA-provided figures; instead, CMS used enrollment figures estimated internally.

Information Collection/Reporting Instruments and Instruction/Guidance Documents

Form CMS-43 (Application for Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease) (Revised)

Form CMS-43 elicits the information that SSA -- CMS’ agent for processing Medicare entitlements -- needs to properly determine whether the individual is eligible for Medicare and when coverage can begin.  This form is an essential part of the application process for entitlement to premium-free Part A.

Individuals who are entitled to premium-free Part A are also eligible to enroll in Medicare Part B, as outlined in section 226A(c) of the Act and codified at 42 CFR 407.10(a).  Therefore, Form CMS-43 also elicits information regarding enrollment in Medicare Part B, so that individuals who become entitled to Medicare Part A can also have their enrollment in Part B start simultaneously.

The form consists of 8 sections that must be completed to determine an individual’s eligibility for enrollment in Part A and Part B using on the basis of ESRD.

– Section 1: Basic information 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.

–Section 2: Earnings and work history - Requests information needed to determine insured status. To be entitled to free Part A an individual must be insured, that is, s/he must have worked the required amount of time under Social Security, the railroad retirement board (RRB) or as a government employee REF: §226(a)(1) of the ACT).  Under §205 of the Act, the Commissioner of SSA shall establish and maintain records of the amount of wages paid to each individual and the amount of self-employment income. These earnings are maintained under the worker’s SSN.  The earnings determine an individual’s (or his/her dependent’s) eligibility to benefits and Medicare.  We also request information about the individual’s current earnings and railroad work 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.

Section 3: Citizenship – Requests citizenship, lawful presence and residency information and are 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).

 Section 4: Marital status – Requests marital and spousal information and are 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 spouse’s earnings record.  As previously stated, there are no alternative identifiers that SSA can use to determine earnings information.

Section 5: Medical history - Requests information about the individual’s current health condition and treatment, including dates of dialysis and/or kidney transplant.  This data is used to determine eligibility for Medicare entitlement and the proper date for which Part A and Part B coverage can begin.  As outlined in statute, the dates of entitlement vary depending upon whether the individual is dialyzed or has received a kidney transplant.

Section 6: Enrollment in Medicare Part B - Provides the option to enroll in Medicare Part B.  If an applicant's application is processed more than 5 months after their initial eligibility month for Medicare, they may choose from three coverage start date options for their Part B benefits.

Section 7: Remarks – Provides nine blank lines for applicants who need additional space to complete their responses.  The remarks area can be used to continue Question 3g if applicant requires extra space to list all addresses where they lived during the past five years.  This section can also be used to continue Question 4n if the applicant needs to add information about additional former spouses, including their name, date of birth, SSN, marriage start and end dates, or date of death if applicable. Additionally, applicants may use this area to provide any general comments or additional information regarding their application.

Section 8: Signature(s) – 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.

13.      Capital Costs

There are no capital costs.

14.      Cost to Federal Government
            
Processing Costs

As most of the applications are completed through an in-person interview via telephone with an SSA representative, we estimate it will take the federal government employee 25 minutes (0.42 hours) to collect and review the information of the respondent.  In addition, the medical verification of an ESRD diagnosis and treatment is required to establish eligibility for entitlement.  This is collected using Form CMS-2728 (OMB control number 0938-0046).  Upon collection of the information outlined in both forms, the SSA representative must manually review the application to determine eligibility and process the Medicare entitlement.  We estimate that this recording of information will take a federal government employee 20 minutes (0.33 hours) to complete, based on experience.  Thus, the total time is 45 minutes per respondent.

To derive average wage costs, we used data from the Office of Personnel Management (OPM) 2026 General Schedule (GS) Locality Pay Table for all salary estimates   https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-tables/pdf/2026/GS.pdf.  We estimate that the average government employee at SSA to receive and record the collected data to be Grade 11, Step 5 (GS-11-5), which we believe is the most appropriate level for a SSA representative performing this function.  

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 $34.64 or $72,051 annually.  Therefore, the total cost to the government to complete the annual volume of responses is $1,174,296 (33,900 hours x $34.64 per hour = $1,174,296).  

The burden hours are computed as follows:

Reporting

It is estimated that a federal employee requires 20 minutes (0.33 hours) per response to 
Collect and review the information of the respondent.  With 45,200 responses, the total burden is 14,916 hours (45,200 × 0.33 = 14,916).  At a cost of $11.43 per response, the total cost is $516,636 (45,200 × $11.43).

Record Keeping

It is estimated that a federal employee requires 25 minutes (0.42 hours) per response to record the information.  With 45,200 responses, the total burden is 18,984 hours (45,200 × 0.42 = 18,984). At a cost of $14.55 per response, the total cost is $657,660 (45,200 × $14.55).

Total Cost to the Federal Government 

It is estimated that a federal employee requires 45 minutes (0.75 hours) per response to collect, review, and record the information.  With 45,200 responses, the total burden is 33,900 hours (45,200 × 0.75 = 33,900).  At a cost of $25.98 per response, the total cost is $1,174,296 (45,200 × $25.98).


Time Per Response
Hour Per Response
Annual Hour Burden
Cost Per Response
Annual Cost Burden
Reporting
20 mins
0.33
14,916
$11.43
$516,636
Record Keeping
25 mins
0.42
18,984
$14.55
$657,660
Total
45 mins
0.75
33,900
$25.98
$1,174,296

15.     Changes to Burden

The changes proposed in this 2026 collection of information request are associated with our July 16, 2026 (91 FR 43842) CY 2027 Physician Fee Schedule NPRM (CMS-1848-P, RIN 0938-AV82) and with section 1899C of the Act.

While neither of the two have any impact on our currently approved (active) burden estimates, we are proposing to update our Medicare initial enrollment forms to expand the response options to include specific types of citizenship and alien status data elements to support Medicare Part A enrollment eligibility determinations. 

In alignment with the addition of section 1899C, CMS will update the CMS-43 by revising the existing citizenship section to require applicants to identify their specific citizenship or immigration status.  Applicants will be required to indicate whether they are a U.S. citizen or national; a lawful permanent resident (LPR); a Cuban and Haitian entrant (CHE); or an individual lawfully residing in the U.S. under a Compact of Free Association (COFA).  CMS intends to implement similar updates across other Medicare enrollment forms to ensure consistent collection of necessary information to verify eligibility under the new statutory requirements.

Although the citizenship section has been added to the collection instrument, the hourly burden estimate has not been adjusted because of this addition.  The WFTC legislation narrows the categories of non-citizens eligible for Medicare, which is expected to result in a smaller overall pool of applicants who are not U.S. citizens or nationals.  For the majority of respondents are U.S. citizens or nationals, selecting their status and proceeding to the next section is estimated to take less than one minute and is therefore considered negligible.  For the remaining applicants who select a non-citizen status, SSA already collects documentation related to immigration and residency status as part of its existing enrollment processes, which should minimize any additional burden.  CMS anticipates only a small number of applicants to indicate they may be ineligible under current federal law and that number is expected to be negligible.  Accordingly, no change to the overall burden estimate is warranted at this time.

Additional updates to the CMS-43 include revising the form title from “Application for Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease” to “Application for Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease” to align with other recently approved Medicare enrollment forms that consistently include “Medicare” in the title.  Section headings have also been renamed in accordance with CMS’s Office of Communications (OC) plain language guidance to improve clarity and usability.

An email address field has been added to the “Basic Information” section, consistent with other recently OMB-approved Medicare enrollment forms that include an optional email field.  Providing an email address is voluntary; however, collecting this information allows SSA to communicate with applicants regarding their Social Security and Medicare benefits, as well as the status of their submission.

16.      Publication/Tabulation Data

This information is not published or tabulated.

17.      Expiration Date

The form displays the expiration date in the top right corner of the form. 

18.      Certification Statement

There are no exceptions to the certification statement.

B.     Collection of Information Employing Statistical Methods 

There have been no statistical methods employed in this collection.