Information Collection

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

IC 43672 under ICR 200809-0938-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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 EGWP	Form and Instruction
TK 2010 Direct Contract MA-PD Application.doc	Other-Redline
TK 2010 Direct Contract PDP Application.doc	Other-Redline
TK 2010 EGWP Cost Application.doc	Other-Redline
TK 2010 EGWP PDP Application.doc	Other-redline
TK 2010 PACE Part D.doc	Other-redline
TK 2010 Part D Cost.DOC	Other-redline
TK 2010 Part D MAPD.doc	Other-redline
TK 2010 Part D PDP_draft_0729.doc	Other-redline
TK 2010 Part D SAE application.doc	Other-redline
High level Summ_2010_Application_Revisions_508 and comments.doc	Other-revision
Red line 2010 Part D PDP_508.doc	Other-Red line
Red line 2010 Part D MAPD_508.doc	Other-Red Line
Red line 2010 Part D Cost_508.doc	Other-Red Line
Red line 2010 PACE Part D_508.doc	Other-redline
2010 Part D Cost_508.doc	Other-1
2010 Part D SAE application_508.doc	Other-2
2010 Part D PDP_508.doc	Other-2
2010 Part D MAPD_508.doc	Other-2
2010 PACE Part D_508.doc	Other-3
Red line 2010 Part D SAE application_508.doc	Other-4
CMS-10137 Solicitation for Applications for New Employer/Union Dir 2010 Direct Contract MA-PD_clean081308.doc	Form and Instruction
CMS-10137 2010 Solicitation for Applications for New Employer/Unio 2010 Direct Contract PDP_clean081308.doc	Form and Instruction
CMS-10137 Application Instructions for Cost Plan Sponsors to Offer 2010 EGWP Cost Application_clean081108.doc	Form and Instruction
CMS-10137 2010 Application Instructions for PDP Sponsors to Offer 2010 EGWP PDP Application_clean081108.doc	Form and Instruction
CMS-10137 Medicare Part D Application for New PACE Organizations 2010 PACE Part D_clean081108.doc	Form and Instruction
CMS-10137 Solicitation for Applications for New Cost Plan Sponsors 2010 Part D Cost_clean081108.DOC	Form and Instruction
CMS-10137 Solicitation for Applications for New Medicare Advantage 2010 Part D MAPD_clean081108.doc	Form and Instruction
CMS-10137 Solicitation for Applications for New Prescription Drug 2010 Part D PDP_clean081108.doc	Form and Instruction
CMS-10137 2010 PART D SERVICE AREA EXPANSION APPLICATION 2010 Part D SAE application_clean081108.doc	Form and Instruction
High level Summ_2010_Application_Revisions_081108.DOC High level Summ_2010_Application_Revisions_081108	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 423.153 42 CFR 423.440 42 CFR 423.112 42 CFR 423.514 42 CFR 423.120 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	Solicitation for Applications for New Employer/Union Direct Contract Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors	2010 Direct Contract MA-PD_clean081308.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	2010 Solicitation for Applications for New Employer/Union Direct Contract Prescription Drug Plan (PDP) Sponsors	2010 Direct Contract PDP_clean081308.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	Application Instructions for Cost Plan Sponsors to Offer New Employer/Union-Only Group Waiver Plans (EGWPs)	2010 EGWP Cost Application_clean081108.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	2010 Application Instructions for PDP Sponsors to Offer New Employer/Union-Only Group Waiver Plans (EGWPs)	2010 EGWP PDP Application_clean081108.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	Medicare Part D Application for New PACE Organizations	2010 PACE Part D_clean081108.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	Solicitation for Applications for New Cost Plan Sponsors Contract Year 2010	2010 Part D Cost_clean081108.DOC	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	Solicitation for Applications for New Medicare Advantage Prescription Drug Plan (MA-PD) Sponsors	2010 Part D MAPD_clean081108.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	Solicitation for Applications for New Prescription Drug Plans (PDP) Sponsors	2010 Part D PDP_clean081108.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10137	2010 PART D SERVICE AREA EXPANSION APPLICATION	2010 Part D SAE application_clean081108.doc	Yes	Yes	Paper Only
Other-Redline			TK 2010 Direct Contract MA-PD Application.doc	Yes	Yes	Paper Only
Other-Redline			TK 2010 Direct Contract PDP Application.doc	Yes	Yes	Paper Only
Other-2			2010 Part D SAE application_508.doc	Yes	Yes	Paper Only
Other-2			2010 Part D MAPD_508.doc	Yes	Yes	Paper Only
Other-redline			Red line 2010 PACE Part D_508.doc	Yes	Yes	Paper Only
Other-4			Red line 2010 Part D SAE application_508.doc	Yes	Yes	Paper Only
Other-Red Line			Red line 2010 Part D MAPD_508.doc	Yes	Yes	Paper Only
Other-Redline			TK 2010 EGWP Cost Application.doc	Yes	Yes	Paper Only
Other-redline			TK 2010 EGWP PDP Application.doc	Yes	Yes	Paper Only
Other-redline			TK 2010 PACE Part D.doc	Yes	Yes	Paper Only
Other-redline			TK 2010 Part D Cost.DOC	Yes	Yes	Paper Only
Other-redline			TK 2010 Part D MAPD.doc	Yes	Yes	Paper Only
Other-redline			TK 2010 Part D PDP_draft_0729.doc	Yes	Yes	Paper Only
Other-redline			TK 2010 Part D SAE application.doc	Yes	Yes	Paper Only
Other-3			2010 PACE Part D_508.doc	Yes	Yes	Paper Only
Other-revision			High level Summ_2010_Application_Revisions_508 and comments.doc	Yes	Yes	Paper Only
Other-1			2010 Part D Cost_508.doc	Yes	Yes	Paper Only
Other-2			2010 Part D PDP_508.doc	Yes	Yes	Paper Only
Other-Red line			Red line 2010 Part D PDP_508.doc	Yes	Yes	Paper Only
Other-Red Line			Red line 2010 Part D Cost_508.doc	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	Previously Approved
Annual Number of Responses for this IC	455	455
Annual IC Time Burden (Hours)	11,890	11,890
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
High level Summ_2010_Application_Revisions_081108	High level Summ_2010_Application_Revisions_081108.DOC	09/08/2008

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