Information Collection

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

IC 46152 under ICR 201312-0938-006 · OMB 0938-1013.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.