Medicare Prescription Drug Benefit Program (CMS-10141)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10141 Preparation and Issuance of Model Notices (section 423.120(c)(6))	Form and Instruction	Modified	Repair queued
Attachment 3 - Part D EOB Crosswalk EOB 30 day version.pdf	Supplementary Document	Uploaded 2022-04-13	Repair queued
CMS-10141 - Supporting Statement A.docx	Supporting Statement A	Uploaded 2022-04-27	Repair queued
Attachment 3j - 60 Day Comments and Responses (2).docx	Supplementary Document	Uploaded 2022-04-13	Available
2023 EOB Crosswalk for PRA 10141 Clean.pdf	Supplementary Document	Uploaded 2022-04-13	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8823	Medicare Prescription Drug Benefit Program (Benes)		Modified
231341	Preparation and Issuance of Model Notices (section 423.120(c)(6))	Form and Instruction	Modified
217122	Business Continuity Plans under 422.504(o) and 423.505(p)		Modified
209891	State Eligibility Determinations (423.904(b)) and Reporting (423.910(d))		Unchanged
187164	Medicare Prescription Drug Benefit Program (Plans)	Instruction	Modified

ICR Details

OMB Control No: 0938-0964	ICR Reference No: 202204-0938-002
Status: Received in OIRA	Previous ICR Reference No: 202110-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: 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	Date Submitted to OIRA: 04/27/2022

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2025
Responses	668,128,349	666,813,366
Time Burden (Hours)	54,509,330	6,973,844
Cost Burden (Dollars)	584,811,068	6,252,673

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

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:
	86 FR 72244	12/21/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 24308	04/25/2022
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Preparation and Issuance of Model Notices (section 423.120(c)(6))	CMS-10141	Model Precluded Provider Letter
Business Continuity Plans under 422.504(o) and 423.505(p)
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, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141	Initial Notice Sent to Potentially At-Risk Beneficiaries ,   Second Notice Sent to Beneficiary Designating At-Risk Status ,   Alternate Second Notice Sent to Beneficiary Not Considered At-Risk ,   Model Prescriber Inquiry Letter ,   Model Sponsor Information Transfer Memo ,   3a - 2022 Model Part D Explanation of Benefits (All Sections Included) ,   3b - Exhibit A: Example Cover Page of the Model Part D EOB ,   3c - Exhibit B: Examples of Section 1 (the List of Prescriptions) ,   3d - Exhibit C: Example of Section 2 (Drug Payment Stages) ,   3e - Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs) ,   3f - Exhibit E: Example of Section 4 (Changes to the Formulary) ,   3g - Exhibit F: Example of Sections 5 and 6 (Information for Reference) ,   3h - Exhibit G: Example of a Part D EOB (All Sections Included)
State Eligibility Determinations (423.904(b)) and Reporting (423.910(d))

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ICR Summary of Burden

table that charts list of burden

	Total Request	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	668,128,349	666,813,366	0	-102	1,315,085	0
Annual Time Burden (Hours)	54,509,330	6,973,844	0	47,204,136	331,350	0
Annual Cost Burden (Dollars)	584,811,068	6,252,673	0	578,558,395	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Total responses increased by 983, and the annual burden hours increased by 47,206,376. The net change in burden reflects revisions to Part D EOB revision of burden hours necessary for plans to read accompanying memo and instructions in the standardized document, 6 hours to generate the standardized document and 1 hour to submit the materials; an increase in number of sponsors required to create business continuity plans; an increase in annual exceptions received and a clerical oversight when calculating total burden There was a net increase of 328,689 responses to account for new Part D and MA plans as a proportion of those required to develop business continuity strategies (10 percent of 942 Part D plans plus estimated 5 MA plans), and because of the increased number of expected exception requests by 1,315,000 (4,500,000 minus 3,185,000). Thus, there was an additional 1,125,000 hours (4,500,000 x 0.25 hours) of burden, for a combined addition of 1,129,960 hours. CMS also included a one time burden adjustment of an additional 7,536 hours in regards to adding additional time to implement changes.

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Annual Cost to Federal Government: $778

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? 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: 04/27/2022

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