Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10169 Change of Ownership (CHOW) Purchaser Form	Form and Instruction	New	Available
Form CMS-10169 Change of Ownership (CHOW) Contract Supplier Notification Form	Form and Instruction	New	Repair queued
Form CMS-10169 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure	Form and Instruction	Modified	Available
Form CMS-10169 Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D)	Form and Instruction	Modified	Repair queued
Form CMS-10169 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Quarterly Reporting Form (Form C)	Form and Instruction	Modified	Available
Form CMS-10169 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Bidding Form (Form B)	Form and Instruction	Removed	Available
Form CMS-10169 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Application for Suppliers (Form A)	Form and Instruction	Removed	Available
Crosswalk for Changes to Subcontracting Form.docx	Supplementary Document	Uploaded 2013-05-10	Available
Crosswalk for Changes to Form C.docx	Supplementary Document	Uploaded 2013-05-10	Available
Form B-6.jpg	Supplementary Document	Uploaded 2012-07-25	Available
Form B-5.jpg	Supplementary Document	Uploaded 2012-07-25	Repair queued
Form B-4.jpg	Supplementary Document	Uploaded 2012-07-25	Repair queued
Form B-3.jpg	Supplementary Document	Uploaded 2012-07-25	Available
Form B-2.jpg	Supplementary Document	Uploaded 2012-07-25	Available
Form B-1.jpg	Supplementary Document	Uploaded 2012-07-25	Repair queued
6-cbas and product categories Screen View.JPG	Supplementary Document	Uploaded 2012-07-25	Repair queued
5-additional locations Screen View.JPG	Supplementary Document	Uploaded 2012-07-25	Repair queued
4-add location Screen View.JPG	Supplementary Document	Uploaded 2012-07-25	Available
3-CBAs and Product Categories Screen View.JPG	Supplementary Document	Uploaded 2012-07-25	Available
2-Location Specific Information Screen View.JPG	Supplementary Document	Uploaded 2012-07-25	Repair queued
1-Business Org Screen View.JPG	Supplementary Document	Uploaded 2012-07-25	Repair queued
1 Network Business Org Screen View.JPG	Supplementary Document	Uploaded 2012-07-25	Repair queued
CMS-10169.Crosswalks for Form A.xlsx	Supplementary Document	Uploaded 2012-07-25	Available
CMS-10169 - Supporting Statement part A (rev 5-10-2013 at 3_00 pm).docx	Supporting Statement A	Uploaded 2013-05-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206873	Change of Ownership (CHOW) Purchaser Form	Form and Instruction	New
206872	Change of Ownership (CHOW) Contract Supplier Notification Form	Form and Instruction	New
203541	Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure	Form and Instruction	Modified
203540	Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D)	Form and Instruction	Modified
203539	Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Quarterly Reporting Form (Form C)	Form and Instruction	Modified
203538	Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Bidding Form (Form B)	Form and Instruction	Removed
203537	Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Application for Suppliers (Form A)	Form and Instruction	Removed

ICR Details

OMB Control No: 0938-1016	ICR Reference No: 201305-0938-005
Status: Historical Active	Previous ICR Reference No: 201207-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: 19556
Title: Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program
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: 06/10/2013
	Date Received in OIRA: 05/10/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved	10/31/2015
Responses	20,212	0	16,865
Time Burden (Hours)	9,301	0	34,795
Cost Burden (Dollars)	0	0	0

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Abstract: In preparing for the Round 2 and national mail-order competitions, CMS received OMB approval of this collection on November 2, 2011 with no material or non-substantive changes. The collection was modified from prior rounds of competitive bidding in order to make the documents more reader-friendly, to clarify the requirements that suppliers had difficulty in understanding, and to incorporate the Round 2 and national mail order bidding areas and product categories. CMS is currently re-competing the Round 1 Rebid areas. On 10/10/12, we received approval for a revision to a currently approved collection to extend the information collection for an additional three years. We are seeking OMB approval for a revision to this currently approved package as our program expands and increases the population from which we will be collecting information.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 302(b)(1) Name of Law: Payment for durable medical equipment; competitive acquisition of certain items and services
   PL: Pub.L. 110 - 275 154 Name of Law: Delay in and Reform of Medicare DMEPOS Competitive Acquisition Program
  

Citations for New Statutory Requirements: PL: Pub.L. 110 - 275 154 Name of Law: Delay in and Reform of Medicare DMEPOS Competitive Acquisition Program

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 13878	03/31/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 27399	05/10/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Quarterly Reporting Form (Form C)	CMS-10169	Form C: QUARTERLY REPORT
Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D)	CMS-10169	Beneficiary Survey
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Subcontracting Disclosure	CMS-10169	CONTRACT SUPPLIER'S DISCLOSURE OF SUBCONTRACTORS
Change of Ownership (CHOW) Contract Supplier Notification Form	CMS-10169	Change of Ownership (CHOW) Contract Supplier Notification Form
Change of Ownership (CHOW) Purchaser Form	CMS-10169	Change of Ownership (CHOW) Purchaser Form
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Application for Suppliers (Form A)	CMS-10169	Application for Suppliers
Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Bidding Form (Form B)	CMS-10169	Form B - Bidding Form

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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	20,212	16,865	203	3,144	0	0
Annual Time Burden (Hours)	9,301	34,795	157	-25,651	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: Yes

Burden Reduction Due to: Changing Forms

Short Statement: Total burden associated with this ICR is increasing as the program expands in accordance with statutory mandates. Forms A and B are not part of this package but will be added before their use, upon OMB approval.

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Annual Cost to Federal Government: $1,437,666

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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 05/10/2013

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