Information Collection

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

IC 43672 under ICR 200710-0938-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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 PACE Medicare Part D Application for New PACE Organizations 2009 Contract Year Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP	Form and Instruction
Form CMS-10137 COST Solicitation for Applications for New Cost Plan Sponsors Contract Year 2009 Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP	Form and Instruction
Form CMS-10137 MAPD Solicitation for Applications for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors 2009 Contract Year Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP	Form and Instruction
Form CMS-10137 PDP Solicitation for Applications for New Prescription Drug Plans (PDP) Sponsors 2009 Contract Year Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP	Form and Instruction
Form CMS-10137 SAE 2009 PART D SERVICE AREA EXPANSION APPLICATION for PRESCRIPTION DRUG PLAN (PDP) SPONSORS and MEDICARE ADVANTAGE PRESCRIPTION DRUG PLAN MEDICARE ADVANTAGE PRESCRIPTION DRUG PLAN contract year 2009 Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP	Form and Instruction
Form CMS-10137 Employer 2009 Solicitation for Applications for New Employer/Union Direct Contract Medicare Advantage Prescription Drug Plan (MA-PD) Sponcors Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP	Form and Instruction
Form CMS-10137 Employer 2009 Solicitation for Applications for New Employer/Union Direct Contract Prescription Drug Plan (PDP) Sponsors Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP	Form and Instruction
Form CMS-10137 EGWP COS 2009 Application Instructions for Cost Plan Sponsors to Offer New Employer/Union-Only Group Waiver Plans (EGWPs) Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP	Form and Instruction
Form CMS-10137 EGWP PDP 2009 Application Instructions for PDP Sponsors to Offer New Employer/Union-Only Group Waiver Plans (EGWPs) Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP	Form and Instruction
redline2009 PACE Part D Applicationdraft1205.doc	Other-redline
redline2009cost_draft1205.DOC	Other-redline
redline2009mapd_draft1205.doc	Other-redline
redline 2009pdp_draft1205.doc	Other-redline
redline2009SAE_draft1205.doc	Other-redline
redline 2009 Direct Contract MA-PD Application_OSORA vs FINAL.doc	Other-redline
redline 2009 Direct Contract PDP Application_OSORA vs FINAL.doc	Other-redline
redline 2009 EGWP Cost Application_OSORA vs Final.doc	Other-redline
redline 2009 EGWP PDP Application_OSORA vs Final.doc	Other-redline
CMS-10137 PACE Medicare Part D Application for New PACE Organizations 2 2009 PACE Part D Application_final_1205.doc	Form and Instruction
CMS-10137 COST Solicitation for Applications for New Cost Plan Sponsors 2009 Part D Cost_final_1205.DOC	Form and Instruction
CMS-10137 MAPD Solicitation for Applications for New Medicare Advantage 2009 Part D MAPD_final_1205.doc	Form and Instruction
CMS-10137 PDP Solicitation for Applications for New Prescription Drug 2009 Part D PDP_final_1205.doc	Form and Instruction
CMS-10137 SAE 2009 PART D SERVICE AREA EXPANSION APPLICATION for PRESC 2009 Part D SAE_final_1205.doc	Form and Instruction
CMS-10137 Employer 2009 Solicitation for Applications for New Employer/Unio 2009 Direct Contract MA-PD Application_FINAL.doc	Form and Instruction
CMS-10137 Employer 2009 Solicitation for Applications for New Employer/Unio 2009 Direct Contract PDP Application_FINAL.doc	Form and Instruction
CMS-10137 EGWP COS 2009 Application Instructions for Cost Plan Sponsors to 2009 EGWP Cost Application_Final.doc	Form and Instruction
CMS-10137 EGWP PDP 2009 Application Instructions for PDP Sponsors to Offer 2009 EGWP PDP Application_Final.doc	Form and Instruction
CMS-10137 High level Summ_2009_Application_Revisions_092807.DOC CMS-10137 High level Summ_2009_Application_Revisions_092807	IC Document
CMS-10137 EPOG Part D Applications_High level summary of changes_Final.doc CMS-10137 EPOG Part D Applications_High level summary of changes_Final	IC Document

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 EGWP

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10137 PACE	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 COST	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 MAPD	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 PDP	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 SAE	Yes	Yes	Paper Only
Other-redline		Yes	Yes	Paper Only
Other-redline		Yes	Yes	Paper Only
Other-redline		Yes	Yes	Paper Only
Other-redline		No		Paper Only
Other-redline		No		Paper Only
Form and Instruction	CMS-10137 Employer Union MAPD	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 Employer Union PDP	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 EGWP COST	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 EGWP PDP	Yes	Yes	Paper Only
Other-redline		Yes	Yes	Paper Only
Other-redline		Yes	Yes	Paper Only
Other-redline		Yes	Yes	Paper Only
Other-redline		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: 455

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	455	-402	857
Annual IC Time Burden (Hours)	11,890	-16,232	28,122
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10137 High level Summ_2009_Application_Revisions_092807		10/10/2007
CMS-10137 EPOG Part D Applications_High level summary of changes_Final		10/10/2007

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

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