Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions

Creditable Coverage Disclosure to CMS OnLine Form and Instructions

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1013 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10198 Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form and Instruction
CMS-10198 Creditable Coverage Disclosure to CMS CC Disclosure to CMS Instructions and Screen Shots Clean 0938-1013 CMS 10198final.pdf Form and Instruction
Crosswalk for 0938-1013 CMS-10198 notices.pdf Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.56e

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10198	Creditable Coverage Disclosure to CMS	CC Disclosure to CMS Instructions and Screen Shots Clean 0938-1013 CMS 10198final.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 83,864	Number of Respondents for Small Entity: 8,000

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	83,864	-2,696	86,560
Annual IC Time Burden (Hours)	7,125	-88	7,213
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk for 0938-1013 CMS-10198 notices.pdf	11/22/2013

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