View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

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
	Date Received in OIRA: 10/18/2024
Terms of Clearance:

	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

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Change of Status Notice (MCSN)	CMS-10868, CMS-10868, CMS-10868, CMS-10868, CMS-10868	, , , ,

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	15,655	15,655
Annual Time Burden (Hours)	2,610	2,610
Annual Cost Burden (Dollars)	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.

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

Agency Contact: Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov

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