Application for Participation in Medicare Replacement Drug Demonstration

ICR 200405-0938-006

OMB: 0938-0924

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0924 200405-0938-006
Historical Active
HHS/CMS
Application for Participation in Medicare Replacement Drug Demonstration
New collection (Request for a new OMB Control Number)   No
Emergency 05/28/2004
Approved with change 06/28/2004
Retrieve Notice of Action (NOA) 05/14/2004
This emergency information collection request is approved for a period of 6 months, as amended by CMS. Prior to expiration of this approval, CMS will resubmit the collection to OMB for review under the normal process established by the PRA.
  Inventory as of this Action Requested Previously Approved
01/31/2005 01/31/2005
50,000 0 0
20,417 0 0
0 0 0

Section 641 of the MMA mandated a demonstration that would pay for drugs/biologicals prescribed as replacements for existing covered Medicare drugs. A report to Congress evaluating the impact of this demonstration was also mandated. In order to enroll in this demonstration, a beneficiary will be required to submit the application forms attached. Beneficiaries who wish to be considered for a low income subsidy must also provide the information on the "Application for Financial Assistance".

None
None


No

1
IC Title Form No. Form Name
Application for Participation in Medicare Replacement Drug Demonstration CMS-10113

  Total Approved 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 50,000 0 0 50,000 0 0
Annual Time Burden (Hours) 20,417 0 0 20,417 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
05/14/2004


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