Retiree Drug Subsidy (RDS) Application and Instructions

Forms and Documents

Document Name	Status
Form CMS-10156 Retiree Drug Subsidy (RDS) Application and Instructions Form	Modified
Form CMS-10156 Retiree Drug Subsidy (RDS) Application and Instructions (CMS-10156) Form	New
CMS10156CrosswalkOfChanges.pdf Supplementary Document	2008-12-11
CMS-10156 Additiional Information to OSORA.doc Supplementary Document	2008-12-11
CMS10156SummaryStatement.pdf Supporting Statement A	2008-12-11

IC Document Collections

IC ID	Document Title	Status
8815	Retiree Drug Subsidy (RDS) Application and Instructions Form	Modified
187541	Retiree Drug Subsidy (RDS) Application and Instructions (CMS-10156) Form	New

ICR Details

OMB Control No: 0938-0957	ICR Reference No: 200812-0938-001
Status: Historical Active	Previous ICR Reference No: 200511-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Retiree Drug Subsidy (RDS) Application and Instructions
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: 02/25/2009
	Date Received in OIRA: 12/16/2008
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2012	36 Months From Approved	02/28/2009
Responses	4,500	0	50,000
Time Burden (Hours)	288,000	0	2,025,000
Cost Burden (Dollars)	0	0	0

---

Abstract: Under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and implementing regulations at 42 CFR ?423 Subpart R, Plan Sponsors e.g., employers or unions) that offer prescription drug coverage to their qualifying covered retirees are eligible to receive a 28% tax-free subsidy for allowable drug costs. In order to qualify, a Plan Sponsor must submit a complete application to CMS with a list of retirees for whom it intends to collect the subsidy

---

Authorizing Statute(s): US Code: 42 USC 1395w-132 Name of Law: null
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AN08	Final or interim final rulemaking	70 FR 4194	01/28/2005

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 53027	09/12/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 72486	11/28/2008
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Retiree Drug Subsidy (RDS) Application and Instructions	CMS-10156	RDS Plan Sponsor Application
Retiree Drug Subsidy (RDS) Application and Instructions (CMS-10156)	CMS-10156	RDS Plan Sponsor 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	4,500	50,000	0	0	-45,500	0
Annual Time Burden (Hours)	288,000	2,025,000	0	0	-1,737,000	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: $20,600,000

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

---

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: 12/16/2008

---