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State Eligibility Determinations (423.904(b)) and Reporting (423.910(d))
Medicare Prescription Drug Benefit Program (CMS-10141)
OMB: 0938-0964
IC ID: 209891
OMB.report
HHS/CMS
OMB 0938-0964
ICR 202204-0938-002
IC 209891
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0964 can be found here:
2023-02-22 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
State Eligibility Determinations (423.904(b)) and Reporting (423.910(d))
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Unchanged
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR 423
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
51
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
600,102
0
0
0
0
600,102
Annual IC Time Burden (Hours)
13,260
0
0
0
0
13,260
Annual IC Cost Burden (Dollars)
0
0
0
0
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.