Information Collection

CY 2012-Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP

IC 43672 under ICR 201009-0938-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10137 Cost CY 2012-Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP	Form and Instruction
CMS-10137 Cost Application for New Cost Plan 2012 Cost formatted_clean30day.pdf	Form and Instruction
CMS-10137 PACE Application for New PACE Organization 2012 PACE Part D_clean30day.pdf	Form and Instruction
CMS-10137 PDP Application for New PDP 2012 PDP formatted_clean30day.pdf	Form and Instruction
CMS-10137 SAE SAE Application for PDP and MA-PD 2012 SAE formatted_clean30day.pdf	Form and Instruction
CMS-10137 MA-PD Application for New MA-PD 2012 MA-PD formatted_clean30day.pdf	Form and Instruction
2012 Cost formatted_rl30day.doc 2012 Cost formatted_rl30day	IC Document
2012 MA-PD formatted_rl30day.doc 2012 MA-PD formatted_rl30day	IC Document
2012 PACE Part D_rl30day.doc 2012 PACE Part D_rl30day	IC Document
2012 PDP formatted_rl30day.doc 2012 PDP formatted_rl30day	IC Document

IC Title:

CY 2012-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	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10137 Cost	Application for New Cost Plan	2012 Cost formatted_clean30day.pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 PACE	Application for New PACE Organization	2012 PACE Part D_clean30day.pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 PDP	Application for New PDP	2012 PDP formatted_clean30day.pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 SAE	SAE Application for PDP and MA-PD	2012 SAE formatted_clean30day.pdf	Yes	Yes	Paper Only
Form and Instruction	CMS-10137 MA-PD	Application for New MA-PD	2012 MA-PD formatted_clean30day.pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 295

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	295	-158	453
Annual IC Time Burden (Hours)	3,576	-8,343	11,919
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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