Change Requests

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VA Health Benefits: Application, Update, Hardship Determination - VA Forms 10-10EZ,10-10EZR, 10-10HS

Key Information

Abstract

Title 38 U.S.C. Chapter 17 authorizes VA to provide hospital care, medical services, domiciliary care, and nursing home care to eligible Veterans. Title 38 U.S.C. § 1705 requires VA to design, establish, and operate a system of annual patient enrollment in accordance with a series of stipulated priorities. Title 38 U.S.C. § 1722 establishes eligibility assessment procedures for cost-free VA medical care, based on income levels, which determines whether nonservice-connected and 0% service-connected non-compensable Veterans are able to defray the necessary expenses of care for nonservice-connected conditions. Further, when the Veteran projects that his or her attributable income for the current calendar year would be substantially below the applicable income thresholds, the Veteran would be considered unable to defray the expenses of care and VA may exempt the Veteran from the requirement to pay copayments for hospital or outpatient care. In addition, Section 103 of Public Law 117-168, titled the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics (PACT) Act of 2022, amended Title 38 U.S.C. Section 1710(e) (3), by expanding the health care eligibility benefit for Veterans who participated in a toxic exposure risk activity (TERA) while serving on active duty, active duty for training, or inactive duty training. This collection of information is required to properly administer health benefits to eligible Veterans: a. VA Form 10-10EZ, Application for Health Benefits, is used to collect Veteran information during the initial application process for VA medical care, nursing home, domiciliary, dental benefits, etc. b. VA Form 10-10EZR, Health Benefits Update Form, is used to update a Veteran’s personal information, such as marital status, address, health insurance and financial information, for renewal of health benefits. c. VA Form 10-10HS, Request for Hardship Determination, is used to collect information from Veterans who are in a copay required status for hospital care and medical services, but due to a loss of income project their income for the current year will be substantially below the VA means test limits. These forms collect information to enroll a Veteran for health benefits, establish basic eligibility, determine TERA benefit eligibility, identify 3rd party health insurance coverage, identify prescription copayment, provide for income verification, and serve as a mechanism to make changes upon admission for benefits or yearly financial updates. VA Forms 10-10EZ and 10-10EZR have been updated pursuant to Executive Order 14168. There are no longer gender options, and the “Birth Sex” field has been changed to “Sex."

Federal Register Notices

60-Day FRN	View Notice
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Authorizing Statutes

38 USC Chapter 17	View Law

Pub.L. 117 - 168 103	View Law

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Transfer Order - Surplus Personal Property and Continuation Sheet; SF 123 & 123A

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The SF 123/123A is required by the Administrator of General Services to carry out her discretionary authority under 40 U.S.C. to transfer Federal surplus personal property for donation. The statutory language is as follows: "40 U.S.C. 549 - Sec. 549. Donation of personal property through state agencies. (b) Authorization. - (1) In general. - The Administrator of General Services, in the Administrator's discretion and under regulations the Administrator may prescribe, may transfer property described in paragraph (2) to a state agency."

Federal Register Notices

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Domestic and International Clients Export Services and Customized Forms

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The International Trade Administration’s (ITA) is mandated by Congress to broaden and deepen the U.S. exporter base and to attract inward foreign direct investment. ITA accomplishes this by providing counseling, programs and services to help U.S. organizations export/import and conduct business in overseas markets. This information collection package enables ITA to provide appropriate export services to U.S. exporters and international buyers. The proposed categories of questions are: contact information, organization information, organization type, agreements and confirmations, objectives, products and services, exporting experience, marketing, events and activities, trade fair/show, certified trade missions, trade missions, advocacy, environment, and education. ITA asks only those questions that provide the required information to assist in fulfilling a client's objective for a requested service and/or event/activity.Emergency Justfication:ITA is requesting emergency processing for the revision of this information collection. The justification of this emergency request is due to the Proclamation 10908 of March 26, 2025, “Adjusting Imports of Automobiles and Automobile Parts Into the United States,” in which the President imposed additional tariffs on imports of specified automobiles and automobile parts to eliminate the threat to national security posed by such imports. This Proclamation provided that for automobiles that qualify for preferential tariff treatment under the United States-Mexico-Canada Agreement (USMCA), importers of such automobiles may submit documentation to the Secretary of Commerce (Secretary) identifying the amount of U.S. content in each model imported into the United States. Processing this emergency revision request will aid the Secretary in meeting the requirements of this Proclamation.

Authorizing Statutes

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Medicare Advantage, Medicare Part D, and Medicare Fee-For-Service Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey (CMS-R-246)

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CMS has fielded the MA (Consumer Assessment of Health Care Providers and Systems) CAHPS Survey annually since 1998, the Medicare FFS CAHPS Survey annually since 2000, and the MA DP and Stand Alone PDP CAHPS survey annually since 2006. The Medicare CAHPS is a national survey of health and prescription drug plans conducted at the contract level for MA, MA PD and Stand Alone PDP plans and at the state level for Medicare fee-for-service. Medicare CAHPS provides data to permit preparation of plan performance measures to assist Medicare beneficiaries in their selection of a health and/or prescription drug plan and help policymakers and others assist the Medicare program and Medicare plans design and monitor patient-centered quality improvement initiatives. The 2009 Call letter for MA and MA PD plans requires these plans to contract with private vendors from a list selected by CMS to conduct the 2011 Medicare CAHPS survey for their plan at the contract level and provide the collected data to CMS for analyses and preparation of CAHPS measures for use in consumer and plan reports and for quality improvement purposes for MA, MA PD, and Stand Alone PDP plans. CMS will continue to collect the Medicare FFS CAHPS data from surveys at the state and some sub-state levels. This revision to a currently approved collection is to add questions focusing on care coordination. The Medicare CAHPS survey has taken the OMB No. 0935-0732.

Federal Register Notices

60-Day FRN	View Notice
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Authorizing Statutes

Pub.L. 108 - 173 1860D	View Law

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CAHPS Hospice Survey CMS-10537)

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Hospice currently serves approximately 42% of dying patients in the United States. Medicare covers most hospice patients under a benefit created in 1983 to provide palliative care at the end of life. Despite its 30-year history as a Medicare benefit, to date no single survey has been systematically administered by all hospices across the country to assess experiences of hospice care. This submission requests approval for national implementation of the CAHPS® Hospice Survey and as well as approval for a mode experiment to test for mode effects, if any, when the survey is implemented. The CAHPS® Hospice Survey will sample caregivers of patients who died while under hospice care. Survey administration will start between 2 and 3 months after the death of the patient. The sample will be provided by the hospice program. This information will ultimately be used to improve hospice care throughout the country. The mod experiment is intended to determine what mode effects, if any, are found while implementing the survey. Three modes will be tested: mail-only, telephone-only, and mixed-mode (mail with telephone follow up). The mode experiment will occur simultaneously with the first year of National Implementation of the survey, which is also covered as part of this submission.

Federal Register Notices

60-Day FRN	View Notice
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Authorizing Statutes

Pub.L. 111 - 148 3004	View Law

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Challenges of Operational Environments Study

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Recent suicide clusters aboard Naval vessels (e.g., the USS George Bush, the USS George Washington) have highlighted a critical need to better understand risk factors for suicide among various shipboard environments (e.g., in maintenance yards, at sea). Unfortunately, extremely limited research to date has identified individual and organizational factors that are directly associated with harmful and destructive behaviors, including suicidality, in a variety of Naval environments. In response, the Office of Naval Research and the Defense Health Agency have funded a longitudinal study called the Challenges of Operational Environments Study to identify specific shipboard stressors associated with different phases of the aircraft carrier life cycle and determine the effects of these stressors on Sailor’s mental and behavioral health and readiness. Research is needed to provide the Navy with in-depth information on specific risks to Sailors at each phase of the carrier cycle, such that allocation of resources to prevent suicidality and other mental/behavioral health problems can be tailored to meet potentially unique needs at each phase. Additionally, findings from the proposed effort will be used to develop targeted recommendations to improve Sailor mental health and wellbeing that will be provided directly to Navy leaders.

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Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and CHIP Agencies (CMS-10440)

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Section 1413 of the Affordable Care Act directs the Secretary of HHS to develop and provide to each State a single, streamlined form that may be used to apply for coverage through the Exchange and Insurance Affordability Programs. A state may develop and use its own single streamlined application if approved by the Secretary in accordance with section 1413 and if it meets the standards established by the Secretary.

Federal Register Notices

60-Day FRN	View Notice
30-Day FRN	View Notice

Authorizing Statutes

Pub.L. 111 - 148 1413	View Law

Pub.L. 111 - 152 1314	View Law

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Alternative Pilot Physical Examination and Education Requirements (BasicMed)

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Section 2307 of Public Law 114-190, medical certification of small aircraft pilots, provides that, within 180 days of enactment of Public Law 114-190, the FAA Extension, Safety and Security Act of 2016, the Administrator of the FAA shall issue or revise regulations to ensure that an individual may operate as pilot in command of a covered aircraft if certain provisions stipulated in the Act are met. The Act was enacted July 15, 2016. The use of section 2307 by any eligible pilot is voluntary. Persons may elect to use these alternative pilot physical examination and education requirements or may elect to continue to operate using a third-class or higher medical certificate (information collection 2120-0034).The requirements of section 2307 were codified in 14 CFR parts 61, 91 and newly created part 68

Federal Register Notices

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Authorizing Statutes

49 USC 44701	View Law

49 USC 44702	View Law

49 USC 44703	View Law

49 USC 44709	View Law

49 USC 40113	View Law

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AmeriCorps Member Application, Enrollment, and Exit Forms

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This information collection is a revision of AmeriCorps Member Application, Enrollment, and Exit Form. Applicants will respond to the questions included in this information collection tool to apply to serve as AmeriCorps members, enroll in the National Service Trust, and exit their term of service.

Federal Register Notices

60-Day FRN	View Notice
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Authorizing Statutes

42 USC 12501 et seq	View Law

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Volunteer Service Agreements and Volunteer Service Time and Attendance Record

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The purpose of the collection is to collect information necessary to establish guidelines for acceptance of volunteer services, and to make a determination of individuals ' eligibility and suitability to serve as volunteer in Marketing and Regulatory Programs.

Federal Register Notices

60-Day FRN	View Notice
30-Day FRN	View Notice

Authorizing Statutes

7 USC 2272	View Law

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Employer Information Report (EEO-1)

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Section 709(c) of Title VII of the Civil Rights Act of 1964 (Title VII) requires employers to make and keep records relevant to the determination of whether unlawful employment practices have been or are being committed, to preserve such records, and to produce reports as the Commission prescribes by regulation or order. Pursuant to this statutory authority, the EEOC in 1966 issued a regulation requiring certain employers to file executed copies of the EEO–1 in conformity with the directions and instructions on the form, which called for reporting employee data by job category and by sex and race or ethnicity. Pursuant to Executive Order 11246, the Office of Federal Contract Compliance Programs (OFCCP), U.S. Department of Labor, in 1978 issued its regulation describing the EEO–1 as a report ‘‘promulgated jointly with the Equal Employment Opportunity Commission’’ and requiring certain contractors to submit ‘‘complete and accurate reports’’ annually. Under these authorities, private employers with 100 or more employees and federal contractors that have 50 or more employees and meet certain criteria are required to report annually the number of individuals they employ by job category and by sex and race or ethnicity.

Federal Register Notices

60-Day FRN	View Notice
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Authorizing Statutes

42 USC 2000e-8(c)	View Law

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Federal Railroad Administration Alleged Violation and Inquiry Form

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The FRA Alleged Violation and Inquiry Form is a response to section 307(b) of the Rail Safety Improvement Act of 2008, which requires FRA to “provide a mechanism for the public to submit written reports of potential violations of Federal railroad safety and hazardous materials transportation laws, regulations, and orders to the Federal Railroad Administration.” The FRA Alleged Violation and Inquiry Form allows the public to submit alleged violations, complaints, or inquiries directly to FRA. The form allows FRA to collect information necessary to investigate the alleged violation, complaint, or inquiry, and to follow up with the submitting party. This information collection is voluntary, submitted as needed, and there is no requirement for recordkeeping. Note: FRA has revised the title of OMB Control Number 2130–0590 (formerly titled ‘‘Alleged Violation Reporting Form’’).

Federal Register Notices

60-Day FRN	View Notice
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Authorizing Statutes

Pub.L. 110 - 432 307(b)	View Law

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Improving Customer Experience (OMB Circular A-11, Section 280 Implementation) for the Department of Labor (DOL)

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Abstract

This information collection activity provides a means to garner customer and stakeholder feedback in an efficient, timely manner in accordance with the Administration's commitment to improving customer service delivery as discussed in Section 280 of OMB Circular A-11. As discussed in OMB guidance, agencies should identify their highest-impact customer journeys (using customer volume, annual program cost, and/or knowledge of customer priority as weighting factors) and select touchpoints/transactions within those journeys to collect feedback.

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Nondiscrimination Compliance Information Reporting

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Abstract

Information provides data that assists in ensuring Federal financial assistance recipients do not discriminate in the administration, management, and operation of programs and activities.

Federal Register Notices

60-Day FRN	View Notice
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Authorizing Statutes

Pub.L. 113 - 128 188	View Law

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Equal Employment Opportunity (EEO) Complaint System

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Abstract

As set forth under 29 CFR 1614, the Equal Employment Opportunity (EEO) complaint process prescribes that when an aggrieved individual believes that they have been discriminated against on the basis of their race, color, religion, sex (including sexual orientation, gender identity and expressions, and pregnancy), national origin, age, disability, genetic information (including family medical history), marital status, parental status, political affiliation, military service, and reprisal, the aggrieved individual must consult a Counselor prior to filing a complaint in order to try to informally resolve the matter. NRC employees (current and former) and job applicants can use the NRC’s EEO eFile portal to initiate a request for EEO counseling , submit information about their informal EEO complaint , and view the status of their EEO case(s).

Federal Register Notices

60-Day FRN	View Notice
30-Day FRN	View Notice

Authorizing Statutes

Pub.L. 83 - 703 1 stat. 311	View Law

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Job Corps Health Questionnaire

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Information on the health status of an applicant to Job Corps is obtained when the applicant completes ETA 653 during an interview with the admissions counselor as part of the admissions process.

Federal Register Notices

60-Day FRN	View Notice
30-Day FRN	View Notice

Authorizing Statutes

29 USC 3194-3195	View Law

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Medicare Current Beneficiary Survey (MCBS) (CMS-P-0015A)

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The Medicare Current Beneficiary Survey (MCBS) is a continuous, multipurpose survey of a nationally representative sample of aged, disabled, and institutionalized Medicare beneficiaries. MCBS, which is sponsored by the Centers for Medicare & Medicaid Services (CMS), is the only comprehensive source of information on the health status, health care use and expenditures, health insurance coverage, and socioeconomic and demographic characteristics of the entire spectrum of Medicare beneficiaries. The purpose of this revision is to seek approval for CMS to add new items related to beneficiary-centric provisions of the Inflation Reduction Act (IRA) of 2022 to the MCBS Community Questionnaire beginning in 2025 . The new items cover improved measures, streamlined content, and the addition of important IRA-related topics as requested by OMB in their terms of clearance specified in the approval of the 2024 MCBS.

Federal Register Notices

60-Day FRN	View Notice
30-Day FRN	View Notice

Authorizing Statutes

Pub.L. 111 - 148 3021	View Law

Pub.L. 108 - 173 723	View Law

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Job Corps Application Data

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Abstract

ETA 652, Job Corps Applicant Data Sheet, is critical to the screening process. This form is completed by the admissions representative in collaboration with each applicant to determine the applicant’s eligibility for the Job Corps program in accordance with WIOA and Job Corps policy and to collect socio-demographic and employment barriers information for program planning, evaluation, and data reporting purposes. This ICR also contains verbal questions on dependents and childcare.

Federal Register Notices

60-Day FRN	View Notice
30-Day FRN	View Notice

Authorizing Statutes

29 USC 3194-3195	View Law

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Post Enrollment Data Collection for Job Corps Participants

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The 2014 Workforce Innovation Opportunity Act (WIOA) required the Office of Job Corps to collect and report specific post enrollment outcomes for eligible Job Corps participants beginning in Program Year (PY) 2016. The WIOA performance reporting requirements, which replaced those of the 1998 Workforce Investment Act (WIA), are designed to provide a common set of metrics to be reported by similar programs. WIOA substantially changed many outcome metrics for Job Corps compared to those required under WIA and provided new guidance on the definition of high performing and low performing centers. In order to collect the necessary information to meet the new WIOA reporting requirements, the Office of Job Corps revised its post enrollment data collection system (PEDC) in 2019, which primarily collects data through survey instruments.

Federal Register Notices

60-Day FRN	View Notice
30-Day FRN	View Notice

Authorizing Statutes

Pub.L. 113 - 128 116(b)(2)(A)(ii)	View Law

Pub.L. 113 - 128 159(c) and (d)	View Law

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Student Safety Assessment of Job Corps Centers

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Abstract

The Department of Labor’s Office of Job Corps conducts a Student Safety Assessment. Thes collection of information through this assessment is necessary for program evaluation to gauge active students’ sense of safety and security at centers.

Federal Register Notices

60-Day FRN	View Notice
30-Day FRN	View Notice

Authorizing Statutes

5 USC 552	View Law

5 USC 552(a)	View Law

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Student Experience Assessment of Job Corps Centers

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The Department of Labor’s Office of Job Corps administers the Student Experience Assessment Survey. The collection of information through this assessment is necessary for program evaluation to gauge active students’ satisfaction with the program.

Federal Register Notices

60-Day FRN	View Notice
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Authorizing Statutes

29 USC 3198(a)(1)(2)	View Law

29 USC 3209(b)(2)	View Law

29 USC 3209(f)(1)	View Law

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Job Corps Placement Record

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Abstract

Form ETA-678 is used to obtain information about student training for placement of students in jobs, further education or military service. It is used to evaluate overall program effectiveness and is the only form which documents a student's post-center status. The form is prepared by Job Corps centers and placement specialists for each student separating from Job Corps centers.

Federal Register Notices

60-Day FRN	View Notice
30-Day FRN	View Notice

Authorizing Statutes

29 USC 3199(B)	View Law

29 USC 3191(1)(A)	View Law

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Congregate Housing Services Program

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Abstract

This information is necessary to monitor the use of grant funds for the Congregate Housing Services Program (CHSP) according to statutory, regulatory, and administrative requirements.

Federal Register Notices

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Measures and Methods for the National Reporting System for Adult Education

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Abstract

The respondents are the 57 states/outlying areas that receive adult education state grant funds under the Adult Education and Family Literacy Act (AEFLA). The information collected is the states' annual performance report. OCTAE uses the data to ensure that states meet the performance accountability requirements of AEFLA. In this non request, OCTAE has identified non-substantive, conforming edits in the current ICR under OMB Control No. 1830-0027 to bring it into alignment with the recent Executive Order 14168, Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government. .

Federal Register Notices

60-Day FRN	View Notice
30-Day FRN	View Notice

Authorizing Statutes

29 USC 3292	View Law

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Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form (CMS-10718)

Key Information

Abstract

As established by Section 1851 of the Act, and implementing regulations at §§ 422.50 and 422.60, an MA-eligible individual who meets the eligibility requirements for enrollment into an MA plan may enroll during the enrollment periods specified in §422.62, by completing an enrollment form with the MA organization or enrolling through other mechanisms that the Centers for Medicare & Medicaid Services (CMS) determines are appropriate. In addition, the authority for requiring this data collection for PDP enrollment is section 1860D-1 of the Act, and implementing regulations at §§ 423.30 and 423.32, a Part D-eligible individual who wishes to enroll in a Medicare Prescription Drug Plan (PDP) may enroll during the enrollment periods specified in §423.38, by completing an enrollment form with the PDP, or enrolling through other mechanisms CMS determines are appropriate. We are proposing changes to the current, standard (“long”) model enrollment form which will yield a beneficiary-focused model form to simplify the enrollment process.

Federal Register Notices

60-Day FRN	View Notice
30-Day FRN	View Notice

Authorizing Statutes

Pub.L. 108 - 173 101	View Law

42 USC 1395w–21	View Law

Pub.L. 105 - 33 4001	View Law

42 USC 1395w-101	View Law

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