Supporting Statement Part A
Application For Medicare Part A and Part B Special Enrollment Period
(Exceptional Circumstances)
CMS-10797, OMB 0938-1426
This 2025 iteration is a reinstatement with changes to the previously approved collection. These changes do not propose any policy or eligibility updates.
Medicare is a federal program that provides health insurance for people aged 65 and older, and those under 65 with certain disabilities or end-stage renal disease (ESRD). Together, Medicare Parts A and B comprise the “original” or “traditional” Medicare program.
The first opportunity individuals have to enroll in Part A and Part B is during their initial enrollment period (IEP). The IEP is a 7-month period that usually begins three months before the month in which an eligible individual turns 65 and ends three months after the first month of eligibility. The next opportunity for eligible individuals who do not enroll in premium Part A or Part B during their IEP, if they choose to do so, is in the general enrollment period (GEP) which runs from January 1st through March 31st each year. Individuals who do not enroll during their IEP or the following GEP may be subject to a late enrollment penalty (LEP), unless they qualify for a special enrollment period (SEP).
CMS provides SEPs for individuals experiencing an exceptional circumstance to enroll in Medicare premium Part A and Part B. To utilize these SEPs, an individual would have to submit an enrollment request via the form CMS-10797. The form is used by individuals who have missed an enrollment period due to an exceptional circumstance to enroll in Part A and/or Part B. Individuals complete the form and submit it to SSA to complete the enrollment.
Circumstances), instead of Application for Medicare Part A and Part B Special Enrollment Period (Exceptional Conditions).
The form was updated to add the optional collection of email addresses. In response to SSA technician’s feedback, the form now includes a question that allows the applicant to select a Medicare start date. CMS’ Office of Communications provided feedback on the form design and the layout of the questions. The form was redesigned to give the applicant’s a more user-friendly experience. No additional changes were made, and the burden was not impacted by the changes.
Section 1837(m) of the Social Security Act (the Act) provides authority for the Secretary of the Department of Health and Human Services to establish SEPs for individuals who are eligible to enroll in Medicare and meet such exceptional conditions as the Secretary may provide.
Federal regulation at §§ 406.27 and 407.23 establishes the exceptional conditions SEPs for Medicare parts A and B, respectively.
The form consists of 5 sections that must be completed to determine an individual’s eligibility for enrollment in Part A and Part B using an SEP for exceptional conditions.
Social Security number is requested to allow SSA to access their earnings system to determine if the applicant is eligible for or entitled to premium-free Part A. The Medicare number is requested if the applicant is already a Medicare recipient.
Name
Sex
Date of birth
Place of birth and record of birth
Phone number
Email address (optional)
Individuals select whether they wish to sign up for Part B using this form. This question helps SSA determine what program the individuals would like to enroll in.
Individuals will select from 1 of 5 SEPs, based on their exceptional condition. For certain SEPs, the individual must provide dates in which events happened to trigger the enrollment. Information related to the dates in which an event happened is collected to determine eligibility for an SEP. Without these dates, the technician would not be able to determine if the condition falls within the parameters of the SEP.
The SEPs are:
SEP for Individuals Impacted by an Emergency or Natural Disaster – The individual must provide the month and year in which the declared emergency or natural disaster started and ended.
SEP for Group Health Plan (GHP) or Employer Misrepresentation – The individual must provide proof that the GHP or employer provided misinformation. If proof is not available, the individual may submit an attestation. The attestation helps technicians determine eligibility when tangible evidence is not available.
SEP to Coordinate with Termination of Medicaid Coverage – The individual must be eligible for Medicare and either have lost or will lose Medicaid eligibility on or after January 1, 2023. The individual does not need to provide proof, as the agency will be able to verify. They must select whether they want their coverage to start retroactively or prospectively.
SEP for Formerly Incarcerated Individuals – The individual must provide the month and year in which they were incarcerated and released. Information related to the dates in which an event happened is collected to determine eligibility for an SEP. Without these dates, the technician would not be able to determine if the condition falls within the parameters of the SEP. They must select whether they want their coverage retroactively or prospectively.
SEP for Other Exceptional Conditions – Individuals must provide documentation that shows that an exceptional circumstance, outside of the ones in statute, prevented them from enrolling during another enrollment period. If proof is not available, the individual may submit an attestation. The attestation helps technicians determine eligibility when tangible evidence is not available.
Signature, date signed, and current address
Witness name, signature, and date signed
Used by individuals who are applying for the SEP for Other Exceptional Conditions. The attestation helps technicians determine eligibility when tangible evidence is not available.
The application form 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. The form is only used for enrollment by beneficiaries who could not enroll during another enrollment period due to an exceptional circumstance.
The application form is completed by the individual or by a Social Security Administration (SSA) representative using information provided by the Medicare enrollee during an inperson interview. While the form is owned by CMS, it is not completed by CMS staff. SSA processes Medicare enrollments on behalf of CMS.
3. Use of Information Technology
The paper application form is available on the internet at
(https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms). Individuals complete the form and submit it to SSA, either via US mail or in person at a local field office, for processing. The information completed on the form is reviewed manually by SSA and will be entered into their IT systems by an SSA representative.
Internet Claim (iClaim) Application:
Individuals can access the electronic version of the application and file an online claim via SSA’s website (https://secure.ssa.gov/iClaim/rib). The responses applicants input into iClaim determines the screens/questions they will receive, ensuring they only respond to relevant questions. After completing the online application, claimants or their third-party representatives can submit it electronically to SSA, avoiding the need to visit an SSA office.
Interview/SSA Claim System (MCS/POS/MACADE):
The SSA claim system is an electronic system that technicians use to input data collected from the applicant during an in-person interview. All data, whether collected on paper or online, is stored electronically and transferred to the SSA and CMS master records upon adjudication. The electronic data is retained by both CMS and SSA.
The application does not duplicate any other effort, as the person with Medicare must initiate the request for enrollment into Part A and/or Part B. Use of the application form or contacting SSA telephonically to enroll is the initial request by the individual.
The collected information is not available from any other source.
5. Small Businesses
Small businesses are not affected by the collection of this information.
The information is collected only as needed, and only when an individual requests to enroll in Part A and/or Part B. Each individual respondent uses the form one time when they submit the request to enroll in Part A and/or Part B.
There are no special circumstances that would require an information collection to be conducted in a manner that requires respondents to:
Report information to the agency more often than quarterly;
Prepare a written response to a collection of information in fewer than 30 days after receipt of it;
Submit more than an original and two copies of any document;
Retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years;
Collect data in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study;
Use a statistical data classification that has not been reviewed and approved by OMB;
Include a pledge of confidentiality that is not supported by authority established in statute or regulation that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or
Submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information's confidentiality to the extent permitted by law.
The 60-day notice published in the Federal Register on 10/30/2024 (89 FR 86340).
No comments were received during the 60-day comment period.
The 30-day notice published in the Federal Register on (90 FR 13368) on 3/21/2025.
9. Payment/Gift to Respondents
There are no payments or gifts provided to respondents.
This collection is used solely by SSA for the purpose of enrolling a beneficiary into Medicare Part A or Part B. Both CMS and SSA are responsible for ensuring that all personally identifiable information (PII) remains confidential.
The completed form is not provided to CMS, rather it is stored with SSA Under Privacy Act System of Records Notice (SORN) 60-0090, entitled Master Beneficiary Record, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1826.
There are no sensitive questions associated with this collection. Specifically, the collection does not solicit questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.
12. Burden Estimate (Hours & Wages)
To derive average costs for individuals we used data from the U.S. Bureau of Labor Statistics’ May 2023 National Occupational Employment and Wage Estimates for our salary estimate (www.bls.gov/oes/current/oes_nat.htm). We believe that the burden will be addressed under All Occupations (occupation code 00-0000) at $23.11/hr.
The average completion time for the application and interview is 15 minutes (0.25). We add 39 minutes (0.65 hr) to the interview to account for the time to wait in a SSA field office. In this regard we estimate a total of 0.9 hours (0.25 hr for the interview + 0.65 hr of wait time) for the interview. As demonstrated in the following table, in aggregate we estimate an annual burden of 19,901 hours at a cost of $459,912.
Although technology is used in the collection, processing, and storage of the data, the burden is not reduced by the use of technology. The burden is in the interview to solicit and clarify information that is collected for the application.
Method of Completion |
Number of Respondents |
Time Per Response (hours) |
Total Annual Time (hours) |
Individual ’s Wage ($/hr) |
Total Annual Cost ($) |
Paper Form |
8,653 |
0.25 (15 min) |
2,163 |
$23.11 |
$49,987 |
iClaim |
8,653 |
0.25 (15 min) |
2,163 |
$23.11 |
$49,987 |
Interview |
17,306 |
0.9 hr = [0.25 hr (15 min)+ 0.65 hr (39 min)wait time at the field office] (54 minutes) |
15,575 |
$23.11 |
$359,938 |
TOTAL |
34,612 |
Varies |
19,901 |
$69.33 |
$459,912 |
Collection of Information Instruments and Instruction/Guidance Documents
This application consists of 10 questions that must be answered to determine an individual’s eligibility for enrollment in Part A and Part B using an exceptional circumstance. The form is attached to this information collection request (ICR). The form’s data fields include the Social Security number (SSN) (if the applicant is not a Medicare recipient) or Medicare ID Number (if the applicant is already a Medicare recipient). Our justification for requesting the SSN is attached to this collection of information request. The application can also be completed online under iClaim.
iClaim
iClaim is the online version of the above application used by beneficiaries.
SEP User Interface (UI) Mockups
The UI is what SSA technicians use to input the data from an in-person interview.
SSA Program Operations Manual System (POMS)
o HI 00805.382 Special Enrollment Period (SEP) for Exceptional Conditions o HI 00805.383 Individuals Impacted by an Emergency or Disaster o HI
00805.384 Misrepresentation by Group Health Plan (GHP) or Employer o HI
00805.385 Termination of Medicaid Coverage o HI 00805.386 Formerly
Incarcerated Individuals o HI 00805.387 Other Exceptional Conditions
We estimate an annual burden of 8,653 hours (34,612 respondents x 0.25 hours =
8,653) at a cost of $199,971 (8,653 hours x 23.11/hr), or $5.78 per respondent
($199,971/34,612 respondents).
Number of applications |
Time required |
Total burden hours |
Wage costs |
Total cost |
Cost per respondent |
34,612 |
15 mins (0.25 hours) |
8,653 |
$23.11/hr |
$188,971 |
$5.78 |
Capital Costs
There are no capital costs.
Cost to Federal Government
To derive average costs, we used data from the Office of Personnel Management 2024
General Schedule (GS) Locality Pay Table for all salary estimates (https://www.opm.gov/policy-data-oversight/pay-leave/salarieswages/salarytables/24Tables/html/GS_h.aspx). We estimate that the average government employee salary level at SSA that would be most likely to receive and record the collected data to be a Grade 11, Step 1. Therefore, we think this is the most appropriate level for our wage estimates.
As the processing of this form occurs at the national level and not just one geographic location, we estimate the salary using the national base general schedule. That hourly wage is $29.76/hr or $62,107 annually. Therefore, the total cost to the government to complete the annual volume of responses is $257,513.28 (8,653 hours x $29.76=8,653).
MCS/POS/MACADE technicians use the SEP UI to input data collected from the applicant during an in-person interview.
Based on the information collected on the form, we estimate it will take 15 minutes (0.25) for a federal government employee to review and record the collected data (process the enrollment), either by paper form, electronic submission or in person interview.
We estimate an annual burden of 8,653 hours (34,612 respondents x 0.25 hours = 8,653 hours) at a cost of $257,513 (8,653 hours x $29.76) or $7.44 per respondent ($257,513 /34,612 respondents).
Number of applications |
Time required |
Total burden hours |
Wage costs |
Total cost |
Cost per respondent |
34,612 |
15 mins (0.25 hours) |
8,653 |
$29.76/hr |
$257,513 |
$7.44 |
The burden from CMS’s 2023 approved submission increased in cost from $214,742 to $257,513 for federal government costs – an increase of $42,771. The hourly burden from the 2023 approved submission increased from 7,866 hours to 8,653 hours – an increase of 787 hours. 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.
The form was updated to add the optional collection of email addresses. In response to SSA technician’s feedback, the form now includes a question that allows the applicant to select a Medicare start date. CMS’ Office of Communications provided feedback on the form design and the layout of the questions. The form was redesigned to give the applicant’s a more user-friendly experience. No additional changes were made, and the burden was not impacted by the changes.
Publication/Tabulation Dates
This information is not published or tabulated.
Expiration Date
The form displays the expiration date next to the OMB control number.
Certification Statement
There are no exceptions to the certification statement.
Not applicable. There are no statistical methods.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement A 0938 |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2025-05-23 |