Model Creditable Coverage Disclosure Notices

Forms and Documents

Document Name	Status
04.21.08 CC Discl Notices- justification for chgs for 05 15 08 version #2.doc Justification for No Material/Nonsubstantive Change	2008-04-23

IC Document Collections

IC ID	Document Title	Status
8852	Model Creditable Coverage Disclosure Notices (CMS-10182) Instruction	Modified
45715	Model Creditable Coverage Disclosure Notices (CMS-10182) Instruction	Modified
45714	Model Creditable Coverage Disclosure Notices (CMS-10182) Instruction	Modified

ICR Details

OMB Control No: 0938-0990	ICR Reference No: 200805-0938-003
Status: Historical Active	Previous ICR Reference No: 200610-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Model Creditable Coverage Disclosure Notices
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: 06/09/2008
	Date Received in OIRA: 05/06/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2009	01/31/2009	01/31/2009
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). Model Disclosure Notices were posted in the Federal Register in May 2006 and CMS received one public comment. On February 15, 2007, CMS posted the OMB approved disclosure to CMS forms for use on or after February 15, 2007. This collection is to provide updated Model Disclosure Notices to make non-material changes. Statements in the posted creditable coverage and non-creditable coverage disclosure notices were confusing and need to be corrected.

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

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

IC Title	Form No.	Form Name
Model Creditable Coverage Disclosure Notices (CMS-10182)	CMS-10182 CC, CMS-10182-P, CMS-10182-NC	MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE ,   MODEL INDIVIDUAL PERSONALIZED DISCLOSURE NOTICE ,   MODEL INDIVIDUAL NON-CREDITABLE COVERAGE DISCLOSURE NOTICE
Model Creditable Coverage Disclosure Notices (CMS-10182)
Model Creditable Coverage Disclosure Notices (CMS-10182)

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ICR Summary 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: 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: 05/06/2008

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