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855a Form: What You Should Know

CMS-855A (07/11). IMPACT OF REQUIREMENTS IN FORM OMB REVIEW RE: O.M.B. 1056 Medicare has a number of requirements in its enrollment application for individual health care providers and institutional providers that are not reflected in the form OMB review submitted to the Department of Health and Human Services (RSA) in 2024 (RSA). As a result, the form OMB review submitted was not considered by HHS in determining whether to include Medicare eligibility for these providers. Therefore, if the institutional care provider is included in the Form 3810-H, the requirement for a letter from the Medicare agency to the individual does not exist.  If a person using a Form 3810-H to sign their child's application for insurance or medicare does not have a letter, and thus they are not deemed eligible as an institutional provider, the Form 3810-H may be used for the sole purpose of enrolling a provider in the state Medicare program. The Form 3810-H remains in effect to ensure that all requirements are met. There are a set of specific requirements for Medicare institutional providers that are covered by the form OMB review and are not present in the Form 3810-H. These specific requirements are in effect as of January 1, 2001. These specific requirements are in addition to the form OMB review requirements presented in section 3 (1) (i) through (vii) and (vi) of the Medicare Act and are set forth in Table 12 below. TABLE 12. SPECIFIC REQUIREMENTS FOR FEDERAL REGULATION FORM 3810-H, IMPLICATED PAYMENT PRACTICES FOR IMMIGRANT & CITIZENSHIP INDIVIDUALS, INCLUDING CUSTOMER-CONTROLLED INSTITUTIONS (COMPTON) (a) The Medicare Part B premium is to be fixed over an eighteen-month period and the annual Medicare administrative fee is to be fixed over an eighty-month period. Medicare Part A and Part D cost-sharing amounts are to be fixed over an eight-month period and the Medicare administrative fee is to be fixed over an eighteen-month period.

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