Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form FORM B Bidding Form	Form and Instruction	Modified	Available
Form FORM A Round 1-2019	Form and Instruction	Modified	Available
Form FORM A Single Location Bidder	Form and Instruction	Modified	Available
Form FORM A Network Bidder	Form and Instruction	Modified	Available
Form FORM A Multi Location Bidder	Form and Instruction	Modified	Available
Form CMS-10169 Change of Ownership - Purchaser Form - 30-day notice	Form and Instruction	Removed	Available
Form CMS-10169 CHOW 30-day Notice (Change of Ownership Form)	Form and Instruction	Modified	Available
Form CMS-10169 CHOW 30-day Notice (Change of Ownership Form)	Form and Instruction	Modified	Available
Form CMS-10169 Subcontracting Disclosure	Form and Instruction	Modified	Available
Form FORM D Beneficiary Survey-Spanish Version	Form and Instruction	Modified	Available
Form FORM D Beneficiary Survey-English Version	Form and Instruction	Modified	Available
Form FORM C Semi Annual Report Screen Shot 2	Form and Instruction	Modified	Repair queued
Form FORM C Semi Annual Report Screen Shot 1	Form and Instruction	Modified	Available
Form FORM C SEMI ANNUAL Report e-signature	Form	Modified	Available
CMS-10169 - Revised Supporting Statement part A PRA.docx	Supporting Statement A	Uploaded 2017-03-22	Available
Crosswalk_Form_A_- 508.xlsx	Supplementary Document	Uploaded 2017-02-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
212257	Bidding Form (Form B)	Form and Instruction	Modified	Bidding Form
212256	Application for DMEPOS Competitve Bidding Program (Form A)	Form and Instruction	Modified	Round 1-2019
212256	Application for DMEPOS Competitve Bidding Program (Form A)	Form and Instruction	Modified	Single Location Bidder
212256	Application for DMEPOS Competitve Bidding Program (Form A)	Form and Instruction	Modified	Network Bidder
212256	Application for DMEPOS Competitve Bidding Program (Form A)	Form and Instruction	Modified	Multi Location Bidder
206873	Change of Ownership (CHOW) - Purchaser Form	Form and Instruction	Removed	Change of Ownership - Purchaser Form - 30-day notice
206872	Change of Ownership (CHOW) Forms-60-day & 30-day notices	Form and Instruction	Modified	CHOW 30-day Notice (Change of Ownership Form)
206872	Change of Ownership (CHOW) Forms-60-day & 30-day notices	Form and Instruction	Modified	CHOW 30-day Notice (Change of Ownership Form)
203541	Subcontracting Disclosure	Form and Instruction	Modified	Subcontracting Disclosure
203540	Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D)	Form and Instruction	Modified	Beneficiary Survey-Spanish Version
203540	Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D)	Form and Instruction	Modified	Beneficiary Survey-English Version
203539	Form C-Semi Annual Report Screen Shot	Form and Instruction	Modified	Semi Annual Report Screen Shot 2
203539	Form C-Semi Annual Report Screen Shot	Form and Instruction	Modified	Semi Annual Report Screen Shot 1
203539	Form C-Semi Annual Report Screen Shot	Form	Modified	SEMI ANNUAL Report e-signature

ICR Details

OMB Control No: 0938-1016	ICR Reference No: 201703-0938-014
Status: Historical Inactive	Previous ICR Reference No: 201701-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-10169
Title: Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 04/05/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/23/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2017	36 Months From Approved	05/07/2018
Responses	36,997	0	36,997
Time Burden (Hours)	234,194	0	234,194
Cost Burden (Dollars)	0	0	0

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Abstract: The Medicare DMEPOS Competitive Bidding Program was established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 ("Medicare Modernization Act" or "MMA"). Section 302 of the MMA amended Section 1847 of the Social Security Act to establish the competitive acquisition program and define program requirements. The most recent approval for this information collection request (ICR) was issued by OMB on June 10, 2013. That ICR included the estimated burden to collect the information in bidding Forms A and B for the Round 1 Recompete. We are now seeking approval to collect the information in Forms A and B for competitions that will occur before 2017.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 302(b)(1) Name of Law: Payment for durable medical equipment; competitive acquisition of certain items and services
   PL: Pub.L. 110 - 275 154 Name of Law: Delay in and Reform of Medicare DMEPOS Competitive Acquisition Program
  

Citations for New Statutory Requirements: PL: Pub.L. 110 - 275 154 Name of Law: Delay in and Reform of Medicare DMEPOS Competitive Acquisition Program

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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 71100	10/14/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 5578	01/18/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Subcontracting Disclosure	CMS-10169	Subcontracting Disclosure
Application for DMEPOS Competitve Bidding Program (Form A)	FORM A, FORM A, FORM A, FORM A	Multi Location Bidder ,   Network Bidder ,   Single Location Bidder ,   Round 1-2019
Bidding Form (Form B)	FORM B	Bidding Form
Change of Ownership (CHOW) - Purchaser Form	CMS-10169	Change of Ownership - Purchaser Form - 30-day notice
Change of Ownership (CHOW) Forms-60-day & 30-day notices	CMS-10169, CMS-10169	CHOW 30-day Notice (Change of Ownership Form) ,   CHOW 30-day Notice (Change of Ownership Form)
Form C-Semi Annual Report Screen Shot	FORM C, FORM C, FORM C	SEMI ANNUAL Report e-signature ,   Semi Annual Report Screen Shot 1 ,   Semi Annual Report Screen Shot 2
Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D)	FORM D, FORM D	Beneficiary Survey-English Version ,   Beneficiary Survey-Spanish Version

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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 ICR reflected additional burden for Forms A and B because information had to be collected for Round 1 2017, Round 2 Recompete and the national mail-order recompete. This information has already been collected and therefore is not applicable for this ICR. Information collection for these forms will be applicable when bidding begins for Round 2019. In this ICR, the annual burden for Form A for Round 2019 is 500 responses and 4,175 hours. The annual burden for Form B for Round 2019 is 11,500 responses and 138,000 hours. A decreases in burden associated with these forms represent the consolidation of all CBAs into Round 2019 and more accurate estimates based on our experience from prior rounds of competition.

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Annual Cost to Federal Government: $2,798,264

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]? Yes

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: 03/23/2017

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