Information Collection

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

IC 43672 under ICR 200707-0938-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EPOG	Form and Instruction
CMS-10137-EPOG FINAL 2008_1_12_07 EGWP MAO_InstructionsOnly.doc	Instruction
CMS-10137-EPOG FINAL 2008_1_12_ 07 EGWP PDP_InstructionsOnly.doc	Instruction
CMS-10137 Application New Dug Plans CMS-10137 2008pdpapp02052007.doc	Form and Instruction
CMS-10137 App New Cost Plans CMS-10137 CostPlanPartDApp2008_02052007.DOC	Form and Instruction
CMS-10137 EPOG Direct Contract Plans CMS-10137 EPOG FINAL 2008_2_05_07 DirectPDPApplication.doc	Form and Instruction
CMS-10137 MA Plans CMS-10137 MAPDPartDApp2008_02052007.DOC	Form and Instruction
CMS-10137 SAE Applications CMS-10137 SAEApp2008_011607.doc	Form and Instruction
CMS--10137 EPOG Direct MAPD Plans CMS-10137-EPOG FINAL 2008_1_31_07 DirectMAPDApplication.DOC	Form

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 423.120 42 CFR 423.514 42 CFR 423.112 42 CFR 423.440 42 CFR 423.153 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	Application New Dug Plans	CMS-10137 2008pdpapp02052007.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	App New Cost Plans	CMS-10137 CostPlanPartDApp2008_02052007.DOC	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	EPOG Direct Contract Plans	CMS-10137 EPOG FINAL 2008_2_05_07 DirectPDPApplication.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	MA Plans	CMS-10137 MAPDPartDApp2008_02052007.DOC	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	SAE Applications	CMS-10137 SAEApp2008_011607.doc	Yes	Yes	Paper Only
Form	CMS--10137	EPOG Direct MAPD Plans	CMS-10137-EPOG FINAL 2008_1_31_07 DirectMAPDApplication.DOC	Yes	Yes	Paper Only
Instruction			CMS-10137-EPOG FINAL 2008_1_12_07 EGWP MAO_InstructionsOnly.doc	Yes	Yes	Paper Only
Instruction			CMS-10137-EPOG FINAL 2008_1_12_ 07 EGWP PDP_InstructionsOnly.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 857

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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	857	641	216
Annual IC Time Burden (Hours)	28,122	22,806	5,316
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.