Crosswalk: Application

Revisions to Form CMS 10797 (OMB 0938-1426) Application for Medicare Part A and Part B – Special Enrollment Period (Exceptional Conditions)

The form was updated to include instructions and to provide clarity. There were no statutory changes and the burden was not impacted. Regulatory changes are outlined in the attached Response to Comment document.

Page Number	Original Form	Updated Form	Reason for Change	Burden Effect
Page 1	Instructions Tell Us About Yourself - Gather basic enrollment information.	Instructions	The information was moved to another page to make the form easier to navigate.	N/A
Page 2	SEP (Exceptional Conditions)	Tell Us About Yourself Gather information basic enrollment information. SEP (Exceptional Conditions)	Section 1 – “Tell Us About Yourself” was updated to remove grammatical errors. SEP (Exceptional Conditions) Updates were made to reflect changes in the final rule. Emergency or Disaster – Updated to include authorized representatives as individuals who lived in a disaster area. Also updated to change the duration from 2 months to 6 months. Updated to include only Month and Year of the disaster. Beneficiaries may also include a description of the event. GHP or Employer Misinformation – Updated to be more prescriptive on when misinformation must have been received. Updated to include agents and brokers of health plans as entities that can provide misinformation. Also updated to include the opportunity for the applicant to attest to the misinformation if other evidence is not available. Updated to change the duration from 2 months to 6 months. SEP to Coordinate with Termination of Medicare Coverage – Title changed to “SEP for Termination of Medicaid Eligibility” for simplification. Updated to include an option for retroactive coverage beginning at the date of Medicaid termination after 1/1/23.	N/A
Page 3	Signature	SEP (Exceptional Conditions) cont.. Signature	SEP for Formerly Incarcerated Individuals – Updated to include on month and year of incarceration and release. Updated to increase the SEP timeframe from 3 months to 12 months. Allows the applicant to choose an effective date either retrospective or prospective. Also updated to allow retroactive coverage back to the date of release, not to exceed 6 months. SEP for Other Exceptional Conditions – Updated to include the opportunity to attest to the circumstance, if other evidence is not available. Updated to change the duration to a case-by-case basis, not less than 6 months. Signature – Updated with CMS OGC approved language about the penalties of falsification.	N/A
Page 4	N/A	Privacy Notice PRA Disclsoure	The notices page was added to provide applicants with information related to this collection.	N/A
Page 5	N/A	Attestation	This page collects basic enrollment information again, in case the form is misplaced from the original application. This form also asks for detailed information related the GHP or Employer SEP and the SEP for Other Exceptional Circumstance. This includes, approximate dates, missed enrollment periods, and other involved parties.	N/A
Page 6	N/A	Attestation cont.	This page provides a blank space for applicants to provide their detailed account of misinformation.	N/A