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

Forms and Documents

Document Name	Status
Form CMS-10797 Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) Form and Instruction	New
CMS-10797.Supporting Statement .docx Supporting Statement A	2022-07-05

IC Document Collections

IC ID	Document Title	Status
254496	Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202207-0938-005
Status: Received in OIRA	Previous ICR Reference No:
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	Date Submitted to OIRA: 07/05/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	31,499	0
Time Burden (Hours)	7,875	0
Cost Burden (Dollars)	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	Proposed rulemaking	87 FR 25090	04/27/2022

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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

IC Title	Form No.	Form Name
Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)	CMS-10797	CMS 10797 Application for Part A and Part B Special Enrollment Period Exceptional Circumstances_508

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ICR Summary of Burden

	Total Request	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	31,499	0	31,499	0	0	0
Annual Time Burden (Hours)	7,875	0	7,875	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: $214,987

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: 07/05/2022

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