Model Creditable Coverage Disclosure Notices (CMS-10182)

Model Creditable Coverage Disclosure Notices

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0990 can be found here:

Documents and Forms

Document Name Document Type
CMS-10182 09.15.06 CC Guidance Updated Final - 09.12.06.doc Instruction
Redline Model Creditable Coverage Disclosure Notice 02.15.07 vs 05.15.08.doc Other-Redline CC
Redline Model Non Creditable Coverage Disclosure Notice 02.15.07 vs 05.15.08.doc Other-Redline Non-CC
Redline Model Personalized Disclosure Notice 02.15.07 vs 05.15.08.doc Other-Redline Personalized
CMS-10182 CC MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE 04.21.08 PRA CC disclosure - Updated for 05 15 08.doc Form
CMS-10182-P MODEL INDIVIDUAL PERSONALIZED DISCLOSURE NOTICE 04.21.08 PRAModel-Personalized-Disclosure-Notice for 05 15 08.doc Form
CMS-10182-NC MODEL INDIVIDUAL NON-CREDITABLE COVERAGE DISCLOSURE NOTI ~$.21.08 PRA Non-CC disclosure Updated for 05 15 08.doc Form

Information Collection (IC) Details

IC Title:	Model Creditable Coverage Disclosure Notices (CMS-10182)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.56

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-10182 09.15.06 CC Guidance Updated Final - 09.12.06.doc	Yes	Yes	Printable Only
Form	CMS-10182 CC	MODEL INDIVIDUAL CREDITABLE COVERAGE DISCLOSURE NOTICE	04.21.08 PRA CC disclosure - Updated for 05 15 08.doc	Yes	Yes	Paper Only
Form	CMS-10182-P	MODEL INDIVIDUAL PERSONALIZED DISCLOSURE NOTICE	04.21.08 PRAModel-Personalized-Disclosure-Notice for 05 15 08.doc	Yes	Yes	Paper Only
Form	CMS-10182-NC	MODEL INDIVIDUAL NON-CREDITABLE COVERAGE DISCLOSURE NOTICE	~$.21.08 PRA Non-CC disclosure Updated for 05 15 08.doc	Yes	Yes	Paper Only
Other-Redline CC			Redline Model Creditable Coverage Disclosure Notice 02.15.07 vs 05.15.08.doc	Yes	Yes	Paper Only
Other-Redline Non-CC			Redline Model Non Creditable Coverage Disclosure Notice 02.15.07 vs 05.15.08.doc	Yes	Yes	Paper Only
Other-Redline Personalized			Redline Model Personalized Disclosure Notice 02.15.07 vs 05.15.08.doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 444,613	Number of Respondents for Small Entity: 37,697

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,182,671	1,182,671
Annual IC Time Burden (Hours)	508,549	508,549
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.