Creditable Coverage Disclosure to CMS OnLine Form and Instructions (CMS-10198)

Forms and Documents

Document	Type	Status	Availability
Form CMS-10198 Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Form and Instruction	Modified	Repair queued
Form CMS-10198 Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Form and Instruction	Modified	Repair queued
Justification for Nonsubstantive Change.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2016-04-04	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
46153	State, Local, or Tribal Governments - Creditable Coverage Disclosure to CMS OnLine Form and Instructions		Unchanged
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: 201604-0938-001
Status: Historical Active	Previous ICR Reference No: 201312-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Creditable Coverage Disclosure to CMS OnLine Form and Instructions (CMS-10198)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/11/2016
	Date Received in OIRA: 04/05/2016
Terms of Clearance:

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

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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.

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Authorizing Statute(s): Statute at Large: 1 Stat. 1860 Name of Statute: null
  

Citations for New Statutory Requirements: None

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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 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

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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

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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	86,744	0	0	0	0
Annual Time Burden (Hours)	7,364	7,364	0	0	0	0
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.

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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

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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: 04/05/2016

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