Crosswalk

Revisions to Form CMS-10798 (OMB 0938-1425) APPLICATION FOR ENROLLMENT IN PART B
IMMUNOSUPPRESSIVE DRUG COVERAGE
This form was updated to make “Application for Medicare Part B Immunosuppressive Drug Coverage” the title of the form and to
update the language and format to have uniformity with other recently updated A/B forms per the Office of Communications’ plain
language suggestions.
Changes
Updated Form

Original Form

Reason for Change

Page 1:

Page 2:

Information
reformatted to be more
user friendly and reflect
the format of other
updated A/B forms

No attestation check
box confirming the
individual will notify
SSA within 60 days of
gaining qualifying
insurance

Per Office of Communications’
(OC) plain language suggestion,
the language is being updated for
more clarity.

Page 2:

Added an email
address field to update
communication
efforts.
Added checkbox to
confirm permission to
communicate with the
enrollee via email.

No attestation check
box acknowledging
false statements

This form is being updated to
mirror the format of other
recently updated Medicare Part A
and B enrollment forms.
Going forward, all renewed
Medicare A/B forms will include a
privacy statement.
Email was added to bring the
form current to modern
communication efforts.
Added more specific attestations
so individuals are clear on the
statements they are agreeing to.

Burden
Effect
N/A

Included specific
examples of
disqualifying health
coverage so
individuals know
which qualify.