Information Collection

Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EPOG

IC 43672 under ICR 200611-0938-011 · OMB 0938-0936.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0936 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10137 EPOG Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EPOG	Form and Instruction
CMS-10137 SAE Application DraftSAEApp2008_120806.doc	Form and Instruction
CMS-10137 Application for New PDP Draft2008pdpapp120706.doc	Form and Instruction
CMS-10137 Application for New MA-PD DraftMAPDPartDApp2008_120706 (2).doc	Form and Instruction
CMS-10137 Application for New Cost Plan DraftCostPlanPartDApp2008_120706 (2).doc	Form and Instruction
CMS-10137 Application for New PDP CMS-10137 2008pdpappdraft110606 clean version.doc	Form and Instruction
CMS-10137 SAE Application CMS-10137 Clean SAEApp2008_110706.doc	Form and Instruction
CMS-10137 Application for New Cost Plan CMS-10137 CostPlanPartDApp2008_110606cleanversion.DOC	Form and Instruction
CMS-10137 EPOG Application for EPOG CMS-10137-EPOG DRAFT_2008_DirectMAPDApplication.clean.DOC	Form and Instruction
CMS-10137 Application for New Employer CMS-10137 EPOG DRAFT_2008_DirectPDPApplication.clean.doc	Form and Instruction
CMS-10137 Application for New MA-PD CMS-10137 MAPDPartDApp2008_110606clean version.DOC	Form and Instruction
CMS-10137 EPOG Application for New EPOG PDP CMS-10137-EPOG Draft_EGWP New PDP_app_11.08.06.clean.doc	Form and Instruction
CMS-10137 EPOG Application for Existing PDP CMS-10137-EPOG Draft_EGWP_Existing PDP_app_11.08.06.clean.doc	Form and Instruction
CMS-10137 EPOG Application for EPOG Cost Plans CMS-10137-EPOG EGWPCost_DRAFT 11.08.06.clean.doc	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EPOG

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 423.112 42 CFR 423.440 42 CFR 423.153 42 CFR 423.120 42 CFR 423.514 42 CFR 423.512

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10137 EPOG	Application for EPOG Cost Plans	CMS-10137-EPOG EGWPCost_DRAFT 11.08.06.clean.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	Application for New Cost Plan	DraftCostPlanPartDApp2008_120706 (2).doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	Application for New PDP	Draft2008pdpapp120706.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	Application for New MA-PD	DraftMAPDPartDApp2008_120706 (2).doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	SAE Application	DraftSAEApp2008_120806.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	Application for New PDP	CMS-10137 2008pdpappdraft110606 clean version.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	SAE Application	CMS-10137 Clean SAEApp2008_110706.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	Application for New Cost Plan	CMS-10137 CostPlanPartDApp2008_110606cleanversion.DOC	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 EPOG	Application for EPOG	CMS-10137-EPOG DRAFT_2008_DirectMAPDApplication.clean.DOC	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	Application for New Employer	CMS-10137 EPOG DRAFT_2008_DirectPDPApplication.clean.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	Application for New MA-PD	CMS-10137 MAPDPartDApp2008_110606clean version.DOC	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 EPOG	Application for New EPOG PDP	CMS-10137-EPOG Draft_EGWP New PDP_app_11.08.06.clean.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 EPOG	Application for Existing PDP	CMS-10137-EPOG Draft_EGWP_Existing PDP_app_11.08.06.clean.doc	Yes	Yes	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 216

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	216	115	101
Annual IC Time Burden (Hours)	5,316	1,488	3,828
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.