Model Creditable Coverage Disclosure Notices

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10182 NC Important Notice From [Insert Name of Entity] About	Form and Instruction	Modified	Available
Form CMS-10182 NC Important Notice from [Insert Name of Entity] About	Form and Instruction	Modified	Available
Form CMS-10182 CC-SP Aviso Importante de [Inserte el Nombre de la Entidad] Sobre su Cobertura para Recetas M?dicas y Medicare	Form and Instruction	Modified	Available
Form CMS-10182 NC-SP Aviso Importante de [Inserte el Nombre de la Entidad] Sobre su Cobertura para Recetas M?dicas y Medicare	Form and Instruction	Modified	Available
CC Notice Crosswalk Document.DOC	Supplementary Document	Uploaded 2008-10-08	Available
CMS-10182 CC Supporting Statement PRA Disclosure to Ind 06.06.08.doc	Supporting Statement A	Uploaded 2008-10-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8852	Model Creditable Coverage Disclosure Notices (CMS-10182)	Form and Instruction	Modified	Important Notice From [Insert Name of Entity] About
8852	Model Creditable Coverage Disclosure Notices (CMS-10182)	Other-10182 CC-Track change	Modified
8852	Model Creditable Coverage Disclosure Notices (CMS-10182)	Form and Instruction	Modified	Important Notice from [Insert Name of Entity] About
8852	Model Creditable Coverage Disclosure Notices (CMS-10182)	Form and Instruction	Modified	Aviso Importante de [Inserte el Nombre de la Entidad] Sobre su Cobertura para Recetas M?dicas y Medicare
8852	Model Creditable Coverage Disclosure Notices (CMS-10182)	Form and Instruction	Modified	Aviso Importante de [Inserte el Nombre de la Entidad] Sobre su Cobertura para Recetas M?dicas y Medicare
45715	Model Creditable Coverage Disclosure Notices (CMS-10182)	Other-Guidance	Modified
45714	Model Creditable Coverage Disclosure Notices (CMS-10182)	Other-Guidance	Modified

ICR Details

OMB Control No: 0938-0990	ICR Reference No: 200810-0938-015
Status: Historical Active	Previous ICR Reference No: 200805-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Model Creditable Coverage Disclosure Notices
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/24/2008
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/29/2008
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2011	36 Months From Approved	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). Updated 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. CMS updated in 2008 the Model Disclosure Notices to make non-material changes and clarifications. This collection is to provide updated Model Disclosure Notices to be used beginning in 2009 as part of the renewal/reinstatement process. CMS recommends eliminating the Model Personalized Disclosure Notice to lessen the burden on the public. CMS has revised the Model Creditable Coverage Disclosure Notice and the Model Non-Creditable Coverage Disclosure Notice to incorporate the personalized information contained in the previously approved Model Personalized Disclosure Notice.

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

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:
	73 FR 43449	07/25/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 57631	10/03/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Model Creditable Coverage Disclosure Notices (CMS-10182)	CMS-10182 CC-SP, CMS-10182 NC-SP, CMS-10182 NC, CMS-10182 NC	Aviso Importante de [Inserte el Nombre de la Entidad] Sobre su Cobertura para Recetas M?dicas y Medicare ,   Aviso Importante de [Inserte el Nombre de la Entidad] Sobre su Cobertura para Recetas M?dicas y Medicare ,   Important Notice from [Insert Name of Entity] About ,   Important Notice From [Insert Name of Entity] About
Model Creditable Coverage Disclosure Notices (CMS-10182)
Model Creditable Coverage Disclosure Notices (CMS-10182)

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ICR Summary of Burden

table that charts list 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: $100,000

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: 10/29/2008

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