Environmental Health Hazards Checklist Medicare Coverage for Individuals Exposed to Environmental Health Hazards (CMS-10902)

Forms and Documents

Document Name	Status
Form CMS-10902 Environmental Health Hazards Checklist Form and Instruction	New
CMS-10902_Supporting Statement Part A.docx Supporting Statement A	2024-11-22

IC Document Collections

IC ID	Document Title	Status
272603	Environmental Health Hazards Checklist Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202411-0938-009
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CM
Title: Environmental Health Hazards Checklist Medicare Coverage for Individuals Exposed to Environmental Health Hazards (CMS-10902)
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/22/2024

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	61	0
Time Burden (Hours)	10	0
Cost Burden (Dollars)	0	0

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Abstract: The form is used to determine if an individual meets the eligibility criteria to establish entitlement to Hospital Insurance (Part A) and enrollment in Supplementary Medical Insurance (Part B) on the basis of an Environmental Health Hazard. It is completed and signed by the individual’s provider.

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Authorizing Statute(s): US Code: 42 USC 1395rr–1 Name of Law: Medicare Coverage for Individuals Exposed to Environmental Health Hazards
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 72402	09/05/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 92689	11/22/2024
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
Environmental Health Hazards Checklist	CMS-10902, CMS-10902	Environmental Health Hazards Checklist (English) ,   Environmental Health Hazards Checklist (Spanish)

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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	61	0	0	0	0	61
Annual Time Burden (Hours)	10	0	0	0	0	10
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:

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Annual Cost to Federal Government: $349

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]? Yes

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: 11/22/2024

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