CMS-10198 CC Disclosure to CMS Form Crosswalk 2009-07-02

Crosswalk 2007 to 2010

“Disclosure to CMS Form” Document

CMS-10198 (0938-1013)

There are no substantive changes to the 2010 document. All revisions are clarifications to existing items.

2007 version --- (Instructions section on first page of the document/screen) Note: Once you have completed Step 3, you should print a copy of the confirmation page for your records.

2010 version --- (Instructions section of the first page of the document/screen) Note: All fields are required unless otherwise indicated.

(The 2010 version gives the User instructions for printing the confirmation page, when the User gets to that step. See the last item of this document for more information)

2007 Version --- (5a) If you selected "Other State-Sponsored" or "OTHER TYPE OF COVERAGE OFFERED TO MEDICARE PART D ELIGIBLE INDIVIDUALS," please specify Other Type of Coverage below.

(5b) Other Type of Coverage

2010 Version --- (5a) If you select “State-Sponsored Plans: Other State-Sponsored” or “Other Type of coverage OFFERED TO MEDICARE Part D ELIGIBLE INDIVIDUALS” option, please explain in the Other Type of Coverage Description Below

(5b) Description of Other Type of Coverage

2007 Version --- (6) How many Prescription Drug Options offered under this Coverage?

2010 Version --- (6) How many Prescription Drug Options offered under this Coverage? (Please enter a numeric value ONLY.)

2007 Version --- The 2007 version does not have verbiage regarding the maximum number of days in a year.

2010 Version --- This verbiage is located above 9a --- * Note: A plan year should contain a maximum of 365 days, unless it is a leap year then there would be a maximum of 366 days. Example, if a plan year beginning date is 10/01/2008 then the plan year ending date should be no later than 09/30/2009.

2007 Version --- (10) Total Number of Medicare Part D Eligible Individuals expected to be covered under these Option(s) as of the Plan Year Beginning Date stated above
2010 Version --- (10) Total Number of Medicare Part D Eligible Individuals expected to be covered under these Option(s) as of the Plan Year Beginning Date stated above (Please enter a numeric value ONLY.)
2007 Version --- (11) Estimated number of those Medicare Part D Eligible Individuals stated above expected to be covered through an Employer/Union Retiree Group Health Plan
2010 Version --- (11) Out of the estimated number of those Medicare Part D Eligible Individuals stated above, expected to be covered through an Employer/Union Retiree Group Health Plan (Please enter a numeric value ONLY.) 2007 Version --- (13a) Is this a change to a previous disclosure to Creditable coverage Status provided to CMS?
Yes No
2010 Version --- (13a) Has your Creditable Coverage Status (Creditable, Non-Creditable, Creditable/Non-Creditable Options Offered) changed from the last plan year? Yes No

2007 Version --- (14c) If no email address is available, Please enter [email protected]

2010 Version --- (14c) If no email address is available, Please enter; [email protected]

2007 Version --- (14d) Date (MM/DD/YYYY)

2010 Version --- (14d) Today’s Date (MM/DD/YYYY)

2007 Version --- (After completing Step 2 the User receives the following message pertaining to Step 3) Thank you! Your Disclosure to CMS Form has been submitted successfully to CMS. Please print a copy of this confirmation page for your records.

2010 Version --- (After completing Step 2 the User receives the following message pertaining to Step 3) Thank you! Your disclosure to CMS form has been submitted successfully to CMS. You will receive a confirmation email for your records. You may also print a copy of this confirmation page.

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