Retiree Drug Subsidy Payment Request Instructions (CMS-10170)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10170 Retiree Drug Subsidy Payment	Form	Modified	Repair queued
Form CMS-10170 Retiree Drug Subsidy Payment	Form	Removed	Repair queued
CMS-10170 - Supporting Statement A.docx	Supporting Statement A	Uploaded 2020-08-14	Available
Justification for Collecting SSNs (2).doc	Supplementary Document	Uploaded 2017-02-22	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8838	Retiree Drug Subsidy (RDS) Payment Request and Instructions (public, private and union sponsors)	Form	Modified	Retiree Drug Subsidy Payment
8838	Retiree Drug Subsidy (RDS) Payment Request and Instructions (public, private and union sponsors)	Instruction	Modified
188650	Public Respondents - Retiree Drug Subsidy (RDS) Payment Request and Instructions	Form	Removed	Retiree Drug Subsidy Payment
188650	Public Respondents - Retiree Drug Subsidy (RDS) Payment Request and Instructions	Instruction	Removed

ICR Details

OMB Control No: 0938-0977	ICR Reference No: 202008-0938-003
Status: Historical Active	Previous ICR Reference No: 201702-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Retiree Drug Subsidy Payment Request Instructions (CMS-10170)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/30/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/17/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2024	36 Months From Approved
Responses	2,159	0	0
Time Burden (Hours)	326,009	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and implementing regulations at 42 CFR ?423 Subpart R, Plan Sponsors (e.g., employers or unions) that offer prescription drug coverage to their qualifying covered retirees are eligible to receive a 28% tax-free subsidy for allowable drug costs. In order to receive the subsidy, a Plan Sponsor must submit required prescription drug cost data and certain other data to CMS.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1860
   US Code: 42 USC 1395 W-132 Name of Law: Special Rules for employer sponsored programs
   US Code: 31 USC 7701(c) Name of Law: Taxpayer identifying number
   US Code: 5 USC 552a Name of Law: Records maintained on individuals
  

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:
	85 FR 34209	06/03/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 48255	08/10/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Public Respondents - Retiree Drug Subsidy (RDS) Payment Request and Instructions	CMS-10170	Retiree Drug Subsidy Payment
Retiree Drug Subsidy (RDS) Payment Request and Instructions (public, private and union sponsors)	CMS-10170	Retiree Drug Subsidy Payment

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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	2,159	0	0	0	-323	2,482
Annual Time Burden (Hours)	326,009	0	0	0	-48,773	374,782
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 total burden is adjusted from 336,428 hr to 326,009 hr due to a reduction in RDS sponsor enrollment.

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Annual Cost to Federal Government: $10,336,720

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.     Yes

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.     Yes

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? No

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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: 08/17/2020

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