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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.