Information Collection

Business Continuity Plans under 422.504(o) and 423.505(p)

IC 217122 under ICR 202003-0938-008 · OMB 0938-0964.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0964 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10141 Business Continuity Plans under 422.504(o) and 423.505(p) Form
Attachment 5b - Instructions for Writing Agents.pdf Instruction
Attachment 5c - Compensation Workbook.pdf Instruction
Attachment 5a - Instructions for MA and PDP Organizations.pdf Instruction
CMS-10141 Compensation Certification to be Completed by Any Organi Attachment 1b - Compensation Certification to be Completed by Any Organization with Renewal Commission.pdf Form
CMS-10141 Compensation Structure for Writing Agents Attachment 2b - Compensation Structure for Writing Agents.pdf Form
CMS-10141 Compensation Certification to be Completed by All Organi Attachment 1a - Compensation Certification to be Completed by All Organizations.pdf Form
CMS-10141 Compensation Structure for Plans Attachment 2a - Compensation Structure for Plans.pdf Form
CMS-10141 Covered Agent Information Sheet CMS-10141.Attachment_3_(Covered_Agent_Information_Sheets_Workbook) (version 2).pdf Form
CMS-10141 Compensation Structure for Writing Agents by Contract/PB CMS-10141.Attachment_4_(Agent_Compensation_Information_Workbook) (version2).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Business Continuity Plans under 422.504(o) and 423.505(p)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.505(p) 42 CFR 422.504(o)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10141	Compensation Certification to be Completed by All Organizations	Attachment 1a - Compensation Certification to be Completed by All Organizations.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10141	Compensation Structure for Plans	Attachment 2a - Compensation Structure for Plans.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10141	Covered Agent Information Sheet	CMS-10141.Attachment_3_(Covered_Agent_Information_Sheets_Workbook) (version 2).pdf	Yes	Yes	Fillable Fileable
Form	CMS-10141	Compensation Structure for Writing Agents by Contract/PBP Number	CMS-10141.Attachment_4_(Agent_Compensation_Information_Workbook) (version2).pdf	Yes	Yes	Fillable Fileable
Instruction			Attachment 5a - Instructions for MA and PDP Organizations.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10141	Compensation Certification to be Completed by Any Organization with Renewal Commission	Attachment 1b - Compensation Certification to be Completed by Any Organization with Renewal Commission.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10141	Compensation Structure for Writing Agents	Attachment 2b - Compensation Structure for Writing Agents.pdf	Yes	Yes	Fillable Fileable
Instruction			Attachment 5b - Instructions for Writing Agents.pdf	Yes	Yes	Fillable Fileable
Instruction			Attachment 5c - Compensation Workbook.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 99	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	99	99
Annual IC Time Burden (Hours)	15,920	15,920
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.