Medicare Prescription Drug Benefit Program - IRASA (CMS-10141)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10141 Model Precluded Provider Letter	Form and Instruction	Modified	Available
Form CMS-10141 Preparation and Issuance of Model Notices (section 423.120(c)(6))	Form and Instruction	Modified	Repair queued
Form CMS-10141 3h - Exhibit G: Example of a Part D EOB (All Sections Included)	Form and Instruction	Modified	Repair queued
Form CMS-10141 3g - Exhibit F: Example of Sections 5 and 6 (Information for Reference)	Form and Instruction	Modified	Available
Form CMS-10141 3f - Exhibit E: Example of Section 4 (Changes to the Formulary)	Form and Instruction	Modified	Available
Form CMS-10141 3e - Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs)	Form and Instruction	Modified	Available
Form CMS-10141 3d - Exhibit C: Example of Section 2 (Drug Payment Stages)	Form and Instruction	Modified	Available
Form CMS-10141 3c - Exhibit B: Examples of Section 1 (the List of Prescriptions)	Form and Instruction	Modified	Available
Form CMS-10141 3b - Exhibit A: Example Cover Page of the Model Part D EOB	Form and Instruction	Modified	Repair queued
Form CMS-10141 3a - 2022 Model Part D Explanation of Benefits (All Sections Included)	Form and Instruction	Modified	Repair queued
Form CMS-10141 Model Sponsor Information Transfer Memo	Form and Instruction	Modified	Available
Form CMS-10141 Model Prescriber Inquiry Letter	Form and Instruction	Modified	Repair queued
Form CMS-10141 Alternate Second Notice Sent to Beneficiary Not Considered At-Risk	Form and Instruction	Modified	Available
Form CMS-10141 Second Notice Sent to Beneficiary Designating At-Risk Status	Form and Instruction	Modified	Available
Form CMS-10141 Initial Notice Sent to Potentially At-Risk Beneficiaries	Form and Instruction	Modified	Available
CMS-10141 - Supporting Statement A_IRASA reporting_.docx	Supporting Statement A	Uploaded 2023-02-17	Repair queued
2023 Crosswalk for PRA 10141.pdf	Supplementary Document	Uploaded 2023-02-15	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	Model Precluded Provider Letter
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))		Modified
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3h - Exhibit G: Example of a Part D EOB (All Sections Included)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3g - Exhibit F: Example of Sections 5 and 6 (Information for Reference)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3f - Exhibit E: Example of Section 4 (Changes to the Formulary)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3e - Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3d - Exhibit C: Example of Section 2 (Drug Payment Stages)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3c - Exhibit B: Examples of Section 1 (the List of Prescriptions)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3b - Exhibit A: Example Cover Page of the Model Part D EOB
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	3a - 2022 Model Part D Explanation of Benefits (All Sections Included)
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	Model Sponsor Information Transfer Memo
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	Model Prescriber Inquiry Letter
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	Alternate Second Notice Sent to Beneficiary Not Considered At-Risk
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	Second Notice Sent to Beneficiary Designating At-Risk Status
187164	Medicare Prescription Drug Benefit Program (Plans)	Form and Instruction	Modified	Initial Notice Sent to Potentially At-Risk Beneficiaries
187164	Medicare Prescription Drug Benefit Program (Plans)	Instruction	Modified

ICR Details

OMB Control No: 0938-0964	ICR Reference No: 202302-0938-009
Status: Historical Active	Previous ICR Reference No: 202204-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Medicare Prescription Drug Benefit Program - IRASA (CMS-10141)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/27/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/22/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2025	36 Months From Approved	09/30/2025
Responses	695,802,400	0	668,128,349
Time Burden (Hours)	25,506,943	0	54,509,330
Cost Burden (Dollars)	599,698,399	0	584,811,068

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Abstract: The purpose of this revision is to account for the burden resulting from the submission of an IRASA reconciliation file. In order for CMS to pay the statutorily-mandated IRA subsidy amount for contract year 2023, Part D sponsors must submit data necessary for CMS to determine that subsidy through the IRASA reconciliation file. The burden associated with the IRASA reconciliation file relates to compiling and sending the file to CMS. The reconciliation file will only be submitted for contract year 2023. In addition, the drug management program (DMP) sections have been revised to remove one-time burden associated with establishing DMPs and initial programming of standardized and model communications. As all Part D sponsors were required to have a DMP by January 1, 2022, this burden is no longer needed. Also, there is a revision associated with a change in burden estimate to create business continuity plans to account for the net increase in responses to account for new plans required to develop business continuity strategies and to account for the increased number of expected exception requests. 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.

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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
   US Code: 42 USC 1395w-115 Name of Law: SUBSIDIES FOR PART D ELIGIBLE INDIVIDUALS FOR QUALIFIED PRESCRIPTION DRUG COVERAGE
  

Citations for New Statutory Requirements: US Code: 42 USC 1395w-115 Name of Law: SUBSIDIES FOR PART D ELIGIBLE INDIVIDUALS FOR QUALIFIED PRESCRIPTION DRUG COVERAGE

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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:
	87 FR 75633	12/09/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 9883	02/15/2023
Did the Agency receive public comments on this ICR? No

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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 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	695,802,400	668,128,349	0	27,674,048	3	0
Annual Time Burden (Hours)	25,506,943	54,509,330	0	-29,002,107	-280	0
Annual Cost Burden (Dollars)	599,698,399	584,811,068	0	14,887,331	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Total responses decreased by 27,674,048 and the annual burden hours decreased by 29,002,387. The net change in burden primarily reflects revisions to the burden estimate for § 423.153(f) Drug management Programs to remove the one-time burden associated with establishing DMPs and initial programming of standardized and model communications. We also note the change in burden estimate to create business continuity plans to account for the net increase in responses to account for new plans required to develop business continuity strategies and to account for the increased number of expected exception requests and the added burden estimate to account for the new requirement for Part D sponsors to submit an IRASA reconciliation file.

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Annual Cost to Federal Government: $838

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: 02/22/2023

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