Applications for Medicare Part D plans: PDP Plans, MA-PD Plans, Cost Plans, PACE organizations, SAE and EGWP

Forms and Documents

Document Name	Status
Form CMS-10137 Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP Form and Instruction	Modified
Comments chart draft.xls Supplementary Document	2008-12-11
Justification for Emergency PRA Clearance.doc Supplementary Document	2008-09-08
High level Summ_2010_Application_Revisions_081108.DOC Supplementary Document	2008-09-08
supporting_statement081108.doc Supporting Statement A	2008-09-08

IC Document Collections

IC ID	Document Title	Status
43672	Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0936	ICR Reference No: 200809-0938-013
Status: Historical Active	Previous ICR Reference No: 200710-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Applications for Medicare Part D plans: PDP Plans, MA-PD Plans, Cost Plans, PACE organizations, SAE and EGWP
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 12/12/2008
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/12/2008
	Date Received in OIRA: 09/18/2008
Terms of Clearance: This ICR is approved consistent with revisions in response to public comments. Previous terms of clearance remain in effect.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2009	6 Months From Approved	01/31/2011
Responses	455	0	455
Time Burden (Hours)	11,890	0	11,890
Cost Burden (Dollars)	0	0	0

---

Abstract: The Applications for Part D sponsors to offer qualified prescription drug coverage are completed by entities seeking approval to offer Part D benefits under the Medicare Prescription Drug Benefit program established by section 101 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and is codified in section 1860D of the Social Security Act (the Act).

Emergency Justfication: See attached emergency justification document. This field only has a 200 max character limit, not 4000 as noted; consequently, the emergency justification is attached as a separate document.

---

Authorizing Statute(s): PL: Pub.L. 108 - 173 1860D Name of Law: Medicare Prescription Drug Benefit Program
   Statute at Large: 18 Stat. 1860 Name of Statute: null
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AP52	Final or interim final rulemaking	73 FR 54226	09/18/2008

---

Federal Register Notices & Comments
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 54160	09/18/2008
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP	CMS-10137, CMS-10137, CMS-10137, CMS-10137, CMS-10137, CMS-10137, CMS-10137, CMS-10137, CMS-10137	Solicitation for Applications for New Employer/Union Direct Contract Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors ,   2010 Solicitation for Applications for New Employer/Union Direct Contract Prescription Drug Plan (PDP) Sponsors ,   Application Instructions for Cost Plan Sponsors to Offer New Employer/Union-Only Group Waiver Plans (EGWPs) ,   2010 Application Instructions for PDP Sponsors to Offer New Employer/Union-Only Group Waiver Plans (EGWPs) ,   Medicare Part D Application for New PACE Organizations ,   Solicitation for Applications for New Cost Plan Sponsors Contract Year 2010 ,   Solicitation for Applications for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors ,   Solicitation for Applications for New Prescription Drug Plans (PDP) Sponsors ,   2010 PART D SERVICE AREA EXPANSION APPLICATION

---

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	455	455	0	0	0	0
Annual Time Burden (Hours)	11,890	11,890	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:

---

Annual Cost to Federal Government: $100,800

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

---

Common Form ICR:  No

---

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: 09/18/2008

---