Information Collection

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

IC 43672 under ICR 200904-0938-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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
2010 Direct Contract MA-PD_508.doc	Instruction
2010 Direct Contract PDP_508.doc	Instruction
2010 EGWP Cost Application_508.doc	Instruction
2010 EGWP PDP Application_508.doc	Instruction
2010 PACE Part D_508.doc	Instruction
2010 Part D Cost_508.DOC	Instruction
2010 Part D MAPD_508.doc	Instruction
2010 Part D PDP_508.doc	Instruction
2010 Part D SAE application_508.doc	Instruction
2010 Chart for New EGWP Applicants _FINAL.doc 2010 Chart for New EGWP Applicants _FINAL	IC Document

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 423.514 42 CFR 423.440 42 CFR 423.153 42 CFR 423.112 42 CFR 423.120 42 CFR 423.512

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	2010 Part D MAPD_508.doc	Yes	Yes	Paper Only
Instruction	2010 Part D PDP_508.doc	Yes	Yes	Paper Only
Instruction	2010 Part D SAE application_508.doc	Yes	Yes	Paper Only
Instruction	2010 Direct Contract MA-PD_508.doc	Yes	Yes	Paper Only
Instruction	2010 Direct Contract PDP_508.doc	Yes	Yes	Paper Only
Instruction	2010 EGWP Cost Application_508.doc	Yes	Yes	Paper Only
Instruction	2010 EGWP PDP Application_508.doc	Yes	Yes	Paper Only
Instruction	2010 PACE Part D_508.doc	Yes	Yes	Paper Only
Instruction	2010 Part D Cost_508.DOC	Yes	Yes	Paper Only

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
2010 Chart for New EGWP Applicants _FINAL	2010 Chart for New EGWP Applicants _FINAL.doc	03/20/2009

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