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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10198 CC Form (screen shot)	Form	Modified	Repair queued
Form CMS-10198 Creditable Coverage Disclosure to CMS	Form and Instruction	Modified	Available
Form CMS-10198 CC Form (screen shot)	Form	Modified	Available
Form CMS-10198 Creditable Coverage Disclosure to CMS	Form and Instruction	Modified	Available
Passback_1_CMS-10198 -Creditable_Coverage_ Supporting Statement A rev 09-18-2017 by OSORA PRA -CLEAN.docx	Supporting Statement A	Uploaded 2017-12-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
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	Modified	CC Form (screen shot)
46152	Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Form and Instruction	Modified	Creditable Coverage Disclosure to CMS
46151	Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Form	Modified	CC Form (screen shot)
46151	Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Form and Instruction	Modified	Creditable Coverage Disclosure to CMS

ICR Details

OMB Control No: 0938-1013	ICR Reference No: 201702-0938-018
Status: Historical Active	Previous ICR Reference No: 201604-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Creditable Coverage Disclosure to CMS OnLine Form and Instructions (CMS-10198)
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: 12/28/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/27/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2020	36 Months From Approved	12/31/2017
Responses	87,265	0	86,744
Time Burden (Hours)	7,272	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
  

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:
	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

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

table that charts list of burden

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

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ICR Summary of Burden

table that charts list 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	87,265	86,744	0	0	521	0
Annual Time Burden (Hours)	7,272	7,364	0	0	-92	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: There are no program changes or any revisions to the instructions and screenshots. Our 5 min/response estimate is unchanged. However, we are correcting and adjusting our burden estimates as follows: The currently approved information collection request inadvertently set out 2,793 states in the ROCIS burden table. This should have been 29 states. We are adjusting our private sector respondent estimate +3,264. The net change is +521 responses and -92 hours.

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Annual Cost to Federal Government: $4,530

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 02/27/2017

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