Medicare Change of Status Notice (MCSN) (CMS-10868)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10868 Medicare Change of Status Notice (MCSN) (Vietnamese)	Form	Modified	Available
Form CMS-10868 Medicare Change of Status Notice (MCSN) (Korean)	Form	Modified	Available
Form CMS-10868 Medicare Change of Status Notice (MCSN) (Chinese)	Form	Modified	Available
Form CMS-10868 Aviso de Cambio de Estado de Medicare	Form	Modified	Available
Form CMS-10868 Medicare Change of Status Notice (MCSN)	Form	Modified	Available
Form CMS-10868 Medicare Change of Status Notice (MCSN)	Form	Modified	Missing upstream
10868-MCSN_SupportingStatement_4204-F_Clean.docx	Supporting Statement A	Uploaded 2024-11-15	Repair queued
10868-MCSN_SupportingStatement_4204-F_508.docx	Supporting Statement A	Uploaded 2024-10-17	Repair queued
10868_MCSN_crosswalk_508.pdf	Supplementary Document	Uploaded 2024-10-15	Available
10868_MCSN_crosswalk_508.pdf	Supplementary Document	Uploaded 2024-10-15	Repair queued
4204-p_MCSN_CommentSummary&Responses.docx	Supplementary Document	Uploaded 2024-10-15	Available
4204-p_MCSN_CommentSummary&Responses.docx	Supplementary Document	Uploaded 2024-10-15	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
264658	Medicare Change of Status Notice (MCSN)	Form	Modified	Medicare Change of Status Notice (MCSN) (Vietnamese)
264658	Medicare Change of Status Notice (MCSN)	Form	Modified	Medicare Change of Status Notice (MCSN) (Korean)
264658	Medicare Change of Status Notice (MCSN)	Form	Modified	Medicare Change of Status Notice (MCSN) (Chinese)
264658	Medicare Change of Status Notice (MCSN)	Form	Modified	Aviso de Cambio de Estado de Medicare
264658	Medicare Change of Status Notice (MCSN)	Form	Modified	Medicare Change of Status Notice (MCSN)
264658	Medicare Change of Status Notice (MCSN)	Form	Modified
264658	Medicare Change of Status Notice (MCSN)	Instruction	Modified

ICR Details

OMB Control No: 0938-1467	ICR Reference No: 202410-0938-018
Status: Active	Previous ICR Reference No: 202401-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Medicare Change of Status Notice (MCSN) (CMS-10868)
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: 11/18/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/18/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2027	36 Months From Approved
Responses	15,655	0	0
Time Burden (Hours)	2,610	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: We are proposing to require hospitals to deliver, as soon as possible after certain conditions are met and prior to release from the hospital, a new standardized beneficiary notice, informing eligible beneficiaries of the change in their status, the resulting effect on Medicare coverage of their stay, and their appeal rights if they wish to challenge that change. This new notice will be called the Medicare Change of Status Notice (MCSN). This is as required by the order from the Federal district court for the District of Connecticut in the case Alexander v. Azar, 613 F. Supp. 3d 559 (D. Conn. 2020)), aff’d sub nom., Barrows v. Becerra, 24 F.4th 116 (2d Cir. 2022).

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Authorizing Statute(s): US Code: 42 USC 1154(a)(18) Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV16	Final or interim final rulemaking	89 FR 83240	10/15/2024

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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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
Medicare Change of Status Notice (MCSN)	CMS-10868, CMS-10868, CMS-10868, CMS-10868, CMS-10868	Medicare Change of Status Notice (MCSN) ,   Aviso de Cambio de Estado de Medicare ,   Medicare Change of Status Notice (MCSN) (Chinese) ,   Medicare Change of Status Notice (MCSN) (Korean) ,   Medicare Change of Status Notice (MCSN) (Vietnamese)

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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	15,655	0	0	15,655	0	0
Annual Time Burden (Hours)	2,610	0	0	2,610	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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: $464

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: 10/18/2024

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