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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10797 SEP UI	Form and Instruction	Modified	Available
Form CMS-10797 iClaim	Form and Instruction	Modified	Available
Form CMS-10797 CMS 10797 Application for Part A and Part B Special Enrollment Period Exceptional Circumstances_508	Form and Instruction	Modified	Available
Form CMS-10797 Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)	Form and Instruction	Modified	Repair queued
CMS-10797 - Supporting Statement A (CMS-4199-F version 11.1).docx	Supporting Statement A	Uploaded 2022-10-28	Repair queued
Response to Comments OMB 0938 1426.pdf	Supplementary Document	Uploaded 2022-10-27	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
254496	Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)	Form and Instruction	Modified	SEP UI
254496	Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)	Form and Instruction	Modified	iClaim
254496	Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)	Form and Instruction	Modified	CMS 10797 Application for Part A and Part B Special Enrollment Period Exceptional Circumstances_508
254496	Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)	Form and Instruction	Modified
254496	Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)	Instruction	Modified

ICR Details

OMB Control No: 0938-1426	ICR Reference No: 202210-0938-009
Status: Historical Active	Previous ICR Reference No: 202207-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) (CMS-10797)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/15/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/28/2022
Terms of Clearance: Prior to the re-submission of the information collection Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) (0938-1426), the agency will evaluate its beneficiaries' application experience and ability to access Special Enrollment Period for Medicare Part A and Part B. The evaluation will inform and be integrated in the agency’s next extension or revision of this information collection. The agency will consult with and provide updates to OMB on this evaluation every 6 months.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2024	36 Months From Approved
Responses	31,465	0	0
Time Burden (Hours)	18,094	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): PL: Pub.L. 116 - 260 120 Name of Law: Consolidated Appropriations Act 2021
  

Citations for New Statutory Requirements: PL: Pub.L. 116 - 260 120 Name of Law: Consolidated Appropriations Act 2021

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AU85	Final or interim final rulemaking	87 FR 66454	11/03/2022

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 25090	04/27/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 66454	11/03/2022
Did the Agency receive public comments on this ICR? Yes

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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 Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)	CMS-10797, CMS-10797, CMS-10797	CMS 10797 Application for Part A and Part B Special Enrollment Period Exceptional Circumstances_508 ,   iClaim ,   SEP UI

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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	31,465	0	31,465	0	0	0
Annual Time Burden (Hours)	18,094	0	18,094	0	0	0
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: This is a new information collection request.

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Annual Cost to Federal Government: $214,742

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.     No

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.     No

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: 10/28/2022

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