Model Creditable Coverage Disclosure Notices

ICR 200603-0938-004

OMB: 0938-0990

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
8852 Migrated
ICR Details
0938-0990 200603-0938-004
Historical Active
HHS/CMS
Model Creditable Coverage Disclosure Notices
New collection (Request for a new OMB Control Number)   No
Emergency 03/29/2006
Approved without change 03/31/2006
Retrieve Notice of Action (NOA) 03/03/2006
  Inventory as of this Action Requested Previously Approved
09/30/2006 09/30/2006
1,225,173 0 0
522,204 0 0
0 0 0

The MMA requires that entities offering prescription drug benefits to Medicare Part D eligible individuals provide a disclosure of Creditable Coverage status of the plan that the individual is enrolled in or seeking to enroll in. CMS posted Model Disclosure Notices that can be used by entities to use on or after May 15, 2006 and upon request by the beneficiary.

None
None


No

1
IC Title Form No. Form Name
Model Creditable Coverage Disclosure Notices CMS-10182

  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 1,225,173 0 0 1,225,173 0 0
Annual Time Burden (Hours) 522,204 0 0 522,204 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.
03/03/2006


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