Retiree Drug Subsidy (RDS) Application and Instructions (CMS-10156)

Forms and Documents

Document Name	Status
CMS-10156 - Supporting Statement A - Passback2 (rev 06-16-2017 by OSORA PRA) CLEAN.docx Supporting Statement A	2017-06-28
Justification for Collecting SSNs.doc Supplementary Document	2013-11-15

IC Document Collections

IC ID	Document Title	Status
8815	Private Sector - Retiree Drug Subsidy (RDS) Application and Instructions Instruction	Modified
187541	Public - Retiree Drug Subsidy (RDS) Application and Instructions Instruction	Modified

ICR Details

OMB Control No: 0938-0957	ICR Reference No: 201702-0938-005
Status: Historical Active	Previous ICR Reference No: 201311-0938-027
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Retiree Drug Subsidy (RDS) Application and Instructions (CMS-10156)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/28/2017
	Date Received in OIRA: 02/23/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved	06/30/2017
Responses	2,482	0	4,500
Time Burden (Hours)	158,848	0	288,000
Cost Burden (Dollars)	0	0	0

---

Abstract: Under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and implementing regulations at 42 CFR ?423 Subpart R, Plan Sponsors e.g., employers or unions) that offer prescription drug coverage to their qualifying covered retirees are eligible to receive a 28% tax-free subsidy for allowable drug costs. In order to qualify, a Plan Sponsor must submit a complete application to CMS with a list of retirees for whom it intends to collect the subsidy

---

Authorizing Statute(s): US Code: 42 USC 1395w-132 Name of Law: 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:
	81 FR 91175	12/16/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 11037	02/17/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Private Sector - Retiree Drug Subsidy (RDS) Application and Instructions	CMS-10156	RDS Application
Public - Retiree Drug Subsidy (RDS) Application and Instructions	CMS-10156	RDS Application

---

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	2,482	4,500	0	-2,018	0	0
Annual Time Burden (Hours)	158,848	288,000	0	-129,152	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The total burden is adjusted from 288,000 hr to 158,848 hr due to a reduction in RDS sponsor enrollment.

---

Annual Cost to Federal Government: $9,200,000

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: 02/23/2017

---