Model Creditable Coverage Disclosure Notices

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS 10182-NC Individual Non-Creditable Coverage Disclosure Notice	Form	Modified	Available
Form CMS 10182-CC Individual Creditable Coverage Disclosure Notice	Form	Modified	Available
Form CMS 10182-P Important Notice from[Insert Name of Enity] About Your Prescription Drug Coverage and Medicare	Form	Modified	Available
Form CMS 10182-NC Individual Non-Creditable Coverage Disclosure Notice	Form	New	Available
Form CMS 10182-CC Individual Creditable Coverage Disclosure Notice	Form	New	Available
Form CMS 10182-P Important Notice from[Insert Name of Enity] About Your Prescription Drug Coverage and Medicare	Form	New	Available
Form CMS 10182-NC Individual Non-Creditable Coverage Disclosure Notice	Form	New	Available
Form CMS 10182-CC Individual Creditable Coverage Disclosure Notice	Form	New	Available
Form CMS 10182-P Important Notice from[Insert Name of Enity] About Your Prescription Drug Coverage and Medicare	Form	New	Available
07.31.06 CC Disclosure Notices PRA Brief Overview .doc	Supplementary Document	Uploaded 2006-09-22	Available
07.19.06 CC Disclosure Notices PRA Responses .doc	Supplementary Document	Uploaded 2006-09-22	Available
Public Comment.pdf	Supplementary Document	Uploaded 2006-09-22	Available
CMS-10182 CC Supporting Statement PRA Disclosure Final20060214 REV.doc	Supporting Statement A	Uploaded 2007-01-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8852	Model Creditable Coverage Disclosure Notices (CMS-10182)	Form	Modified	Individual Non-Creditable Coverage Disclosure Notice
8852	Model Creditable Coverage Disclosure Notices (CMS-10182)	Form	Modified	Individual Creditable Coverage Disclosure Notice
8852	Model Creditable Coverage Disclosure Notices (CMS-10182)	Form	Modified	Important Notice from[Insert Name of Enity] About Your Prescription Drug Coverage and Medicare
8852	Model Creditable Coverage Disclosure Notices (CMS-10182)	Instruction	Modified
45715	Model Creditable Coverage Disclosure Notices (CMS-10182)	Form	New	Individual Non-Creditable Coverage Disclosure Notice
45715	Model Creditable Coverage Disclosure Notices (CMS-10182)	Form	New	Individual Creditable Coverage Disclosure Notice
45715	Model Creditable Coverage Disclosure Notices (CMS-10182)	Form	New	Important Notice from[Insert Name of Enity] About Your Prescription Drug Coverage and Medicare
45715	Model Creditable Coverage Disclosure Notices (CMS-10182)	Instruction	New
45714	Model Creditable Coverage Disclosure Notices (CMS-10182)	Form	New	Individual Non-Creditable Coverage Disclosure Notice
45714	Model Creditable Coverage Disclosure Notices (CMS-10182)	Form	New	Individual Creditable Coverage Disclosure Notice
45714	Model Creditable Coverage Disclosure Notices (CMS-10182)	Form	New	Important Notice from[Insert Name of Enity] About Your Prescription Drug Coverage and Medicare
45714	Model Creditable Coverage Disclosure Notices (CMS-10182)	Instruction	New

ICR Details

OMB Control No: 0938-0990	ICR Reference No: 200610-0938-010
Status: Historical Active	Previous ICR Reference No: 200603-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Model Creditable Coverage Disclosure Notices
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/05/2007
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/18/2006
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2009	36 Months From Approved	01/31/2007
Responses	1,225,173	0	1,225,173
Time Burden (Hours)	522,204	0	522,204
Cost Burden (Dollars)	0	0	0

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Abstract: 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 in May 2005 for entities to use between November 15, 2005 and May 15, 2006 (the initial enrollment period for Part D). This collection is to provide Model Disclosure Notices that can be used by entities to use on or after May 15, 2006 and upon request by the beneficiary. Model Disclosure Notices were posted in the Federal Register in May 2006 and CMS received one public comment. CMS has made minor revisions to the Personalized Model Disclosure form as a result of this public comment.

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Authorizing Statute(s): Statute at Large: 1 Stat. 1860
  

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:
	71 FR 27726	05/12/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 55478	09/22/2006
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Model Creditable Coverage Disclosure Notices (CMS-10182)	CMS 10182-P, CMS 10182-CC, CMS 10182-NC	Important Notice from[Insert Name of Enity] About Your Prescription Drug Coverage and Medicare ,   Individual Creditable Coverage Disclosure Notice ,   Individual Non-Creditable Coverage Disclosure Notice
Model Creditable Coverage Disclosure Notices (CMS-10182)	CMS 10182-P, CMS 10182-CC, CMS 10182-NC	Important Notice from[Insert Name of Enity] About Your Prescription Drug Coverage and Medicare ,   Individual Creditable Coverage Disclosure Notice ,   Individual Non-Creditable Coverage Disclosure Notice
Model Creditable Coverage Disclosure Notices (CMS-10182)	CMS 10182-P, CMS 10182-CC, CMS 10182-NC	Important Notice from[Insert Name of Enity] About Your Prescription Drug Coverage and Medicare ,   Individual Creditable Coverage Disclosure Notice ,   Individual Non-Creditable Coverage Disclosure Notice

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ICR Summary of Burden

table that charts list of burden

	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	1,225,173	0	0	0	0
Annual Time Burden (Hours)	522,204	522,204	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Changing Forms

Short Statement: Due to identity and privacy concerns, CMS eliminated the Social Security Number and Health Insurance Claim Number from the Model Personalized Disclosure Notice and replaced it with use of a beneficiary's Date of Birth or Member Identification number. This change did not impact the burden.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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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: 09/25/2006

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