View Information Collection Request (ICR) Package
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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:
0938-1426
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:
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
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.
Authorizing Statute(s):
PL:
Pub.L. 116 - 260 120
Name of Law: Consolidated Appropriations Act 2021
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
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
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, CMS-10797
Application for Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)
,
iClaim
,
SEP UI
ICR Summary 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.
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
Agency Contact:
Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov
Common Form ICR:
No
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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