CMS-10797.Supporting Statement

Supporting Statement Part A

Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) CMS-10797, OMB 0938-New

Background

Medicare is a Federal program to provide health insurance for people age 65 and older, and those under 65 with certain disabilities or end-stage renal disease (ESRD). Together, Medicare Parts A and B comprise “original” or “traditional” Medicare.

The first opportunity individuals have to enroll in Part A and Part B is during their initial enrollment period (IEP). The IEP is a 7-month period that usually begins three months before the month in which an eligible individual turns 65 and ends three months after the first month of eligibility. The next opportunity for eligible individuals who do not enroll in premium Part A or Part B during their IEP, if they choose to do so, is in the general enrollment period (GEP) which runs from January 1st through March 31st each year. Individuals who do not enroll during their IEP or the following GEP may be subject to a late enrollment penalty (LEP), unless they qualify for a special enrollment period (SEP). Several SEPs currently exist that permit individuals to enroll in premium Part A or Part B outside of the IEP or GEP, including the most frequently used SEP for employer group health plan coverage.

Under proposed rule CMS 4199-P, CMS is proposing to provide SEPs for individuals experiencing an exceptional circumstance to enroll in Medicare premium Part A and Part B. To utilize these new SEPs, an individual would have to submit an enrollment request via the form CMS-10797. The form would be used by individuals who have missed an enrollment period due to an exceptional

circumstance to enroll in Part A and/or Part B.

1. Justification

1. Need and Legal Basis

Section 1837(m) of the Act provides authority for the Secretary of the Department of Health and Human Services to establish SEPs for individuals who are eligible to enroll in Medicare and meet such exceptional conditions as the Secretary may provide, effective January 1, 2023. CMS is proposing to establish new exceptional conditions SEPs under section 1837(m) of the Act in §§ 406.27 and 407.23 for Medicare parts A and B,

respectively.

2. Information Users

The CMS-10797 provides the necessary information to determine eligibility and to process the beneficiary’s request for enrollment in premium Part A or Part B due to an exceptional

circumstance. This form is only used for enrollment by beneficiaries who did not enroll during another enrollment period due to an exceptional circumstance.

Form CMS-10797 is completed by the individual, or is done 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

The form consists of 10 questions that must be answered to determine an individual’s eligibility for enrollment in Part A and Part B using an exceptional circumstance.

Items 1-9 Tell Us About Yourself – The questions request information to identify the applicant and obtain contact information. The identity information includes Social Security number (SSN) or Medicare Number if the applicant is already a Medicare recipient, name, address, date of birth, country of birth, sex, and phone number.

Item 10 Special Enrollment Period

Individuals will select from 1 of 5 SEPs, based on their exceptional circumstance. For certain SEPs, the individual must provide dates in which events happened to trigger the enrollment. The SEPs are:

SEP for Individuals Impacted by an Emergency or Natural Disaster – The individual must provide the dates in which the emergency or natural disaster started and ended.

SEP for Group Health Plan (GHP) or Employer Misrepresentation – The individual must provide proof that the GHP or employer provided misinformation.

SEP to Coordinate with Termination of Medicaid Coverage – The individual must be eligible for Medicare and either currently eligible for Medicaid or have lost Medicaid eligibility on or after January 1, 2023, or the last day of the COVID-19 PHE, whichever is earlier. The individual does not need to provide proof, as the agency will be able to verify.

SEP for Formerly Incarcerated Individuals – The individual must provide the dates in which they were incarcerated and released.

SEP for Other Exceptional Conditions – Individuals must provide documentation that shows that an exceptional circumstance, outside of the ones in statute, prevented them from enrolling during another enrollment period.

3. Use of Information Technology

The form CMS-10797 will be available on the internet at (https://www.cms.gov). Individuals complete the form and submit it to SSA, either via US mail or in person at a local field office for processing. The information completed on the form is reviewed manually by SSA and will be entered into their systems by an SSA representative.

Internet Claim (iClaim) Application:

The public will be able to complete an SEP application online. They access the online claim on SSA’s website. The responses applicants input into iClaim, determines 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.

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 A and Part B. Use of this form or contacting SSA telephonically to enroll is the initial request by the individual.

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 individual requests to enroll in Part A or Part B. Each individual respondent uses the form one time when he or she submits the request to enroll in Part A or Part B. If this information is not collected, the individual cannot enroll in Part A or 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 on April 27, 2022 (87 FR 25090) as part of the proposed rule titled “Medicare Program; Implementing Certain Provisions of the Consolidated Appropriations Act, 2021 and Other Revisions to Medicare Enrollment and Eligibility Rules” (CMS-4199-P; RIN 0938-AU85).

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 enrolling a beneficiary into Medicare Part A or 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)

Wage Estimates

To derive average costs for individuals we used data from the U.S. Bureau of Labor Statistics’ May 2021 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 $28.01/hr.

Burden Estimates

We estimate that there will be approximately 31,499 respondents annually requesting enrollment in Part A or Part B using the form CMS-10797.

The average completion time for the paper CMS-10797 is 15 minutes (0.25). In aggregate we estimate an annual burden of 7,875 hours (31,499 respondents x 0.25 hours/response) at a cost of $220,219.52 (7862 x $28.01/hr) or $6.99 per beneficiary ($220,219.52 / 31,499 respondents).

13. Capital Costs

There are no capital costs.

14. Cost to Federal Government

Processing Costs

Based on the information collected on the form, we estimate it takes the federal government employee 15 minutes (0.25) to review and record the collected data (process the enrollment), either by paper form or telephonic enrollment.

The burden is computed as follows:

It is calculated that the burden hours for responses to be reviewed and recorded in 15 minutes per response to be 7,875 total hours. (31,499 x 0.25 hours (15 minutes) = 7875 total burden hours)

To derive average costs, we used data from the Office of Personnel Management 2022 General Schedule (GS) Locality Pay Table for all salary estimates (https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salary-

tables/22Tables/html/GS_h.aspx). We estimate that the average government employee at SSA to receive and record the collected data to be a Grade 11, Step 1 (GS-11-1) – which we believe is the most appropriate level for a SSA field office representative.

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 $27.30/hr or $56,983 annually. Therefore the total cost to the government to complete the annual volume of responses is $214,987.50 (7875 hours x $27.30/hr =

$214,987.50).

15. Changes to Burden This is a new collection.

16. Publication/Tabulation Dates

This information is not published or tabulated.

17. Expiration Date

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

18. Certification Statement

There are no exceptions to the certification statement.

2. Colle ction of Information Employing Statistical Methods

Not applicable. There are no statistical methods.

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