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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10137 CY 2011-Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP	Form and Instruction	Modified	Available
CMS response United comments from 60 day.xls	Supplementary Document	Uploaded 2009-10-02	Available
30 day_Summ_2011_Application_Revisions_technical and substantive.doc	Supplementary Document	Uploaded 2009-10-02	Available
Red line_2011MA-PD formatted.doc	Supplementary Document	Uploaded 2009-10-02	Available
Red line_2011 SAE formatted.doc	Supplementary Document	Uploaded 2009-10-02	Available
Red line_2011 PACE Part D.doc	Supplementary Document	Uploaded 2009-10-02	Available
Red line_2011 Cost formatted.doc	Supplementary Document	Uploaded 2009-10-02	Available
Red line_2011 PDP formatted.doc	Supplementary Document	Uploaded 2009-10-02	Available
supporting_statement121409.doc	Supporting Statement A	Uploaded 2009-12-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43672	CY 2011-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: 200910-0938-009
Status: Historical Active	Previous ICR Reference No: 200904-0938-006
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: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/23/2009
	Date Received in OIRA: 10/21/2009
Terms of Clearance: This ICR is approved consistent with revised supporting statement. We note that while this ICR is implementing ARRA-related changes, not all of the burden changes are attributable to ARRA. CMS also agrees to pull out all references to "forthcoming guidance" before this instrument is implemented. Consistent with the PRA, this ICR should be re-submitted along with the publication of the draft "forthcoming guidance" documents to the extent the guidance document will result in new information collection, recordkeeping, or disclosure requirements or result in changes to burden or capital costs from existing requirements. Previous terms of clearance remain in effect.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2011	36 Months From Approved	06/30/2010
Responses	453	0	455
Time Burden (Hours)	11,919	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).

---

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:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 30574	06/26/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 50799	10/01/2009
Did the Agency receive public comments on this ICR? Yes

---

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

table that charts list of burden

IC Title	Form No.	Form Name
CY 2011-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	Applications for New Cost Plan Sponsors ,   Medicare Part D Application for New PACE Organizations ,   Applications for New Prescription Drug Plans (PDP) Sponsors ,   Part D Service Area Expansion Application ,   Applications for New Medicare Advantage - Prescription Drug Plans (MA-PD) Sponsors

---

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	453	455	0	-2	0	0
Annual Time Burden (Hours)	11,919	11,890	0	29	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The Part D applications have been revised, and as a result, increased in burden due to the streamlining of separate employer applications into the individual market applications. Further, new regulations were issued since the last major revision of these documents. As a result, new attestation sections were added to the overall applications and many attestations were clarified or corrected to address current CMS policy (see Supporting Statement for more detail).

---

Annual Cost to Federal Government: $140,000

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)? Yes

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: 10/21/2009

---