Creditable Coverage Disclosure to CMS OnLine Form and Instructions

Forms and Documents

Document Name	Status
Form CMS-10198 Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form and Instruction	Modified
Form CMS-10198 Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form and Instruction	Modified
CC Disclosure Burden Estimate 0938-1013 CMS-10198 [rev 11-21-2013 by OSORA PRA].pdf Supplementary Document	2013-11-22
Crosswalk for 0938-1013 CMS-10198 notices.pdf Supplementary Document	2013-11-22
Crosswalk for 0938-1013 CMS-10198 notices.pdf Supplementary Document	2013-11-22
CMS-10198 - Supporting Statement A [rev 11-21-2013 by OSORA PRA].doc Supporting Statement A	2013-11-22

IC Document Collections

IC ID	Document Title	Status
46153	State, Local, or Tribal Governments - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Modified
46152	Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form and Instruction	Modified
46151	Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1013	ICR Reference No: 201312-0938-006
Status: Historical Active	Previous ICR Reference No: 200911-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: 20998
Title: Creditable Coverage Disclosure to CMS OnLine Form and Instructions
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/12/2014
	Date Received in OIRA: 12/06/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2017	36 Months From Approved
Responses	86,744	0	0
Time Burden (Hours)	7,364	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Information collection requirements will ensure that entities that currently provide prescription drug benefits to any Medicare Part D eligible individual disclose to CMS whether the prescription drug benefit that they offer is creditable coverage. The disclosure is required to be provide annually and upon any change that affects whether the coverage is creditable prescription drug coverage. This collection also provides creditable coverage disclosure instructions for entities complying with these infromation collection request.

---

Authorizing Statute(s): Statute at Large: 1 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:
	78 FR 38986	06/28/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 70057	11/22/2013
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	CMS-10198	Creditable Coverage Disclosure to CMS
Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	CMS-10198	Creditable Coverage Disclosure to CMS
State, Local, or Tribal Governments - Creditable Coverage Disclosure to CMS OnLine Form and Instructions

---

ICR Summary 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	86,744	0	0	0	-756	87,500
Annual Time Burden (Hours)	7,364	0	0	0	72	7,292
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: The previous PRA package estimated the number of responses to be 87,500 annually. CMS has adjusted the annual estimated number of responses based on actual contractor data. The annual revised number is 87,265. The change to the annual burden is a mathematical calculation and the result of a decrease in the number of plan who offer private prescription drug coverage to Medicare-eligible individuals. There are no program changes. Revisions to the Instructions and Screen Shots are set out in the Crosswalk and have no impact on prev burden estimates. Revisions are mostly for clarification, to remove redundancy, etc.

---

Annual Cost to Federal Government: $112,000

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]? No

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

---

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: 12/06/2013

---