CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10198 Disclosure to CMS Form	Form	Modified	Available
Form CMS-10198 DIsclosure to CMS Web Page	Form	Modified	Available
Form CMS-10198 Disclosure to CMS Form	Form	Modified	Available
Form CMS-10198 DIsclosure to CMS Web Page	Form	Modified	Available
Form CMS-10198 Disclosure to CMS Form	Form	Modified	Available
Form CMS-10198 DIsclosure to CMS Web Page	Form	Modified	Available
2007.05.31 Explanation of changes to OMB Package No. 0938-1013.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2007-05-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
46153	CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	Form	Modified	Disclosure to CMS Form
46153	CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	Instruction	Modified
46153	CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	Form	Modified	DIsclosure to CMS Web Page
46152	CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	Form	Modified	Disclosure to CMS Form
46152	CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	Form	Modified	DIsclosure to CMS Web Page
46152	CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	Instruction	Modified
46151	CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	Form	Modified	Disclosure to CMS Form
46151	CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	Instruction	Modified
46151	CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	Form	Modified	DIsclosure to CMS Web Page

ICR Details

OMB Control No: 0938-1013	ICR Reference No: 200706-0938-003
Status: Historical Active	Previous ICR Reference No: 200611-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/24/2007
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/12/2007
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2010	01/31/2010	01/31/2010
Responses	450,660	0	450,660
Time Burden (Hours)	37,555	0	37,555
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 38649	07/07/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 63018	10/27/2006
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
CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	CMS-10198, CMS-10198	DIsclosure to CMS Web Page ,   Disclosure to CMS Form
CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	CMS-10198, CMS-10198	DIsclosure to CMS Web Page ,   Disclosure to CMS Form
CREDITABLE COVERAGE DISCLOSURE TO CMS ON-LINE FORM AND INSTRUCTIONS : CMS-10198	CMS-10198, CMS-10198	DIsclosure to CMS Web Page ,   Disclosure to CMS Form

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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	450,660	450,660	0	0	0	0
Annual Time Burden (Hours)	37,555	37,555	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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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: 06/11/2007

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