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 Application for Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)	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	Available
CMS-10797 - Supporting Statement A.docx	Supporting Statement A	Uploaded 2025-06-02	Repair queued
CMS-10797 - Supporting Statement A.docx	Supporting Statement A	Uploaded 2025-03-21	Repair queued
Crosswalk of Changes CMS 10797_508.pdf	Supplementary Document	Uploaded 2025-06-02	Repair queued
Crosswalk of Changes CMS 10797_508.pdf	Supplementary Document	Uploaded 2025-01-22	Available

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	Application for Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)
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: 202501-0938-010
Status: Active	Previous ICR Reference No: 202210-0938-009
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: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/08/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/28/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2028	36 Months From Approved
Responses	34,612	0	0
Time Burden (Hours)	19,901	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: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 86340	10/30/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 13368	03/21/2025
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
Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)	CMS-10797, CMS-10797, CMS-10797	Application for Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) ,   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	34,612	0	0	0	3,147	31,465
Annual Time Burden (Hours)	19,901	0	0	0	1,807	18,094
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 change in burden is due to the increase in respondents and an increase in the federal employee’s wages. The number of respondents newly enrolling in Medicare can vary due to the number of individuals that become eligible yearly.

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Annual Cost to Federal Government: $257,513

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: 03/28/2025

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