Comprehensive Addiction and Recovery Act of 2016 (CARA) / Medicare Prescription Drug Benefit Program (CMS-10141)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10141 Alternate Second Notice	Form	Modified	Available
Form CMS-10141 Second Notice: Your Access to Certain Part D Drugs is Limited	Form	Modified	Available
Form CMS-10141 Initial Notice: Notice of Intent to Limit Your Access to Certain Part D Drugs	Form	Modified	Available
Form CMS-10141 Compensation Structure for Writing Agents by Contract/PBP Number	Form	Modified	Available
Form CMS-10141 Covered Agent Information Sheets Workbook	Form	Modified	Repair queued
Form CMS-10141 Description of Compensation Structure	Form	Modified	Available
Form CMS-10141 Compensation Certification	Form	Modified	Available
CMS-10141 - Supporting Statement A - 05-04-2018 CB - Passback2_cb2 CLEAN.docx	Supporting Statement A	Uploaded 2018-11-21	Available
Crosswalk for Attachments 1 - 5.xlsx	Supplementary Document	Uploaded 2018-05-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8823	Medicare Prescription Drug Benefit Program (Benes)		Unchanged
231341	Preparation and Issuance of Model Notices (section 423.120(c)(6))		New
231340	Creation of Model Notices (Plans) (section 423.120(c)(6))		New
231339	System Programming (Plans) (section 423.120(c)(6))		New
217122	Business Continuity Plans under 422.504(o) and 423.505(p)		Unchanged
209891	State Eligibility Determinations (423.904(b)) and Reporting (423.910(d))		Unchanged
187164	Medicare Prescription Drug Benefit Program (Plans)	Form	Modified	Alternate Second Notice
187164	Medicare Prescription Drug Benefit Program (Plans)	Form	Modified	Second Notice: Your Access to Certain Part D Drugs is Limited
187164	Medicare Prescription Drug Benefit Program (Plans)	Form	Modified	Initial Notice: Notice of Intent to Limit Your Access to Certain Part D Drugs
187164	Medicare Prescription Drug Benefit Program (Plans)	Form	Modified	Compensation Structure for Writing Agents by Contract/PBP Number
187164	Medicare Prescription Drug Benefit Program (Plans)	Form	Modified	Covered Agent Information Sheets Workbook
187164	Medicare Prescription Drug Benefit Program (Plans)	Form	Modified	Description of Compensation Structure
187164	Medicare Prescription Drug Benefit Program (Plans)	Form	Modified	Compensation Certification
187164	Medicare Prescription Drug Benefit Program (Plans)	Instruction	Modified

ICR Details

OMB Control No: 0938-0964	ICR Reference No: 201803-0938-004
Status: Historical Active	Previous ICR Reference No: 201712-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Comprehensive Addiction and Recovery Act of 2016 (CARA) / Medicare Prescription Drug Benefit Program (CMS-10141)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/28/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/09/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2021	36 Months From Approved	11/30/2018
Responses	54,426,919	0	46,099,944
Time Burden (Hours)	8,667,195	0	7,588,143
Cost Burden (Dollars)	0	0	0

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Abstract: Part D plans and, to the extent applicable, MA organizations will use the information discussed below to comply with the eligibility and other requirements associated with their participation in Part D. CMS will use this information from plan sponsors and States to approve contract applications, monitor compliance with contract requirements, make proper payment to plans, and ensure that correct information is disclosed to potential and current enrollees. The new information collection will allow CMS to ensure sponsors have plans in place to restore business operations following a disruption of regular operations. Medicare beneficiaries will use the information provided by the Part D sponsors to make decisions regarding Part D enrollment as well as grievance and appeal requests. Under CMS-4182-P (RIN 0938-AT08), CMS will make the Preclusion List available to Part D sponsors. The Part D sponsors will perform system programming to maintain the Preclusion List in order to reject a pharmacy claim (or deny a beneficiary request for reimbursement) for a Part D drug that is prescribed by an individual on the Preclusion List. CMS will create and disseminate model notices to the prescribers to notify them of their existence on the Preclusion List, while the Part D sponsors will create and disseminate model notices to the Medicare beneficiaries to notify them that the pharmacy claim is being rejected or denied due to the prescriber’s existence on the Preclusion List.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1860
   PL: Pub.L. 108 - 173 101 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
  

Citations for New Statutory Requirements: PL: Pub.L. 108 - 173 101 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT08	Final or interim final rulemaking	83 FR 16440	04/16/2018

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 56336	11/28/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 16440	04/16/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Preparation and Issuance of Model Notices (section 423.120(c)(6))
Business Continuity Plans under 422.504(o) and 423.505(p)
Creation of Model Notices (Plans) (section 423.120(c)(6))
Medicare Prescription Drug Benefit Program (Benes)
Medicare Prescription Drug Benefit Program (Plans)	CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141	Compensation Certification ,   Description of Compensation Structure ,   Covered Agent Information Sheets Workbook ,   Compensation Structure for Writing Agents by Contract/PBP Number ,   Initial Notice: Notice of Intent to Limit Your Access to Certain Part D Drugs ,   Second Notice: Your Access to Certain Part D Drugs is Limited ,   Alternate Second Notice
State Eligibility Determinations (423.904(b)) and Reporting (423.910(d))
System Programming (Plans) (section 423.120(c)(6))

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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	54,426,919	46,099,944	95,242	0	8,231,733	0
Annual Time Burden (Hours)	8,667,195	7,588,143	102,121	0	976,931	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 currently approved ROCIS table (approved by OMB on 10/29/2015) incorrectly set out 7,588,143 hours of burden. This was mistakenly carried over from the initial 06/19/2015 Supporting Statement submission. The subsequent 10/27/2015 submission had set out 8,581,027 hours of burden which was in line with the section 12 burden summary table. That table, however, should have set out 8,581,800 hours (a difference of plus 773 hours). The 773 hour error was in the Medicare Prescription Drug Benefit Program (PLAN) burden which should have been 5,704,645 hours instead of 5,703,872 hours. We are also adjusting our estimates by -18,128 hours, adding 1,402 hours based on the (CMS-4182-F) final rule's CARA provisions, and adding 102,121 hours based on the rule's Preclusion List provisions.

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Annual Cost to Federal Government: $744

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: 05/09/2018

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