Crosswalk

Revisions to Form CMS 10798 (OMB 0938-1428) Application for Enrollment in Part B Immunosuppressive Drug Coverage

The form was updated to clarify the attestation statement. There were no statutory or regulatory changes and the burden was not impacted.

Page Number	Original Form	Updated Form	Reason for Change	Burden Effect
Page 2	By using this form to enroll in the Part B-ID benefit for immunosuppressive drug coverage I attest that: Yes No- I am not enrolled in, and do not expect to enroll in certain, other health insurance coverage, and I will notify Social Security within 60 days if I enroll in other health insurance coverage. *Please refer to page 1 for a complete description of the health insurance coverage that would preclude Part B-ID coverage.	By using this form to enroll in Part B for Immunosuppressive Drug Coverage, I attest that: (Check Yes or No) I am enrolled in, or expect to enroll in, certain other health insurance coverage.* Yes/ No. If No, I will notify Social Security within 60 days if I enroll in other health insurance coverage. Yes/No *Please refer to page 1 for a complete description of the health insurance coverage that would preclude Part B-ID enrollment.	The Social Security Administration (SSA) notified CMS that they have received respondent feedback that the current attestation statement is confusing. Beneficiaries are not certain whether yes or no is the correct choice to affirm the statement. To address the potentially confusing statement, CMS proposes to change the attestation to make it clear that the person is making an affirmative statement that they are enrolled or not. Second, we propose to split the attestation into two separate statements to reduce any confusion. Lastly, CMS updated the note attached to the attestation to replace the word coverage with enrollment. From a policy perspective, CMS believes that the most appropriate word is enrollment.	This change does not affect the burden.