Information Collection

MPPP Model Notices Programming

IC 267917 under ICR 202405-0938-024 · OMB 0938-1475.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1475 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Exhibit 1_Likely to Benefit Notice_ENG_30 Day.docx	Instruction
Exhibit 1_Likely to Benefit Notice_FINAL.docx	Instruction
Exhibit 1.2_Likely to Benefit Notice_SPA_30 Day.docx	Instruction
Exhibit 1.2_Likely to Benefit Notice_SPA_FINAL.docx	Instruction
Exhibit 1.3_Likely to Benefit Instructions_30 Day.docx	Instruction
Exhibit 1.3_Likely to Benefit Instructions_FINAL.docx	Instruction
CMS-10882 Medicare Prescription Payment Plan Participation Request Exhibit 2_Election Request_30 Day.docx	Form and Instruction
CMS-10882 Medicare Prescription Payment Plan Participation Request Exhibit 2_Election Request_FINAL.docx	Form and Instruction
CMS-10882 Part D Sponsor Notice to Acknowledge Acceptance of Elect Exhibit 3_Notice of Election Approval_30 Day.docx	Form and Instruction
CMS-10882 Part D Sponsor Notice to Acknowledge Acceptance of Elect Exhibit 3_Notice of Election Approval_FINAL.docx	Form and Instruction
CMS-10882 Part D Sponsor Notice for Failure to Make Payments under Exhibit 4_Notice of Failure to Pay_30 Day.docx	Form and Instruction
CMS-10882 Part D Sponsor Notice for Failure to Make Payments under Exhibit 4_Notice of Failure to Pay_FINAL.docx	Form and Instruction
CMS-10882 Part D Sponsor Notice for Failure to Make Payments under Exhibit 5_Notice of Involuntary Termination_30 Day.docx	Form and Instruction
CMS-10882 Part D Sponsor Notice for Failure to Make Payments under Exhibit 5_Notice of Involuntary Termination_FINAL.docx	Form and Instruction
CMS-10882 Part D Sponsor Notice of Voluntary Removal from the Medi Exhibit 6_Notice of Voluntary Termination_30 Day.docx	Form and Instruction
CMS-10882 Part D Sponsor Notice of Voluntary Removal from the Medi Exhibit 6_Notice of Voluntary Termination_FINAL.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

MPPP Model Notices Programming

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

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
Instruction			Exhibit 1_Likely to Benefit Notice_FINAL.docx	Yes	No	Printable Only
Instruction			Exhibit 1.2_Likely to Benefit Notice_SPA_FINAL.docx	Yes	No	Printable Only
Instruction			Exhibit 1.3_Likely to Benefit Instructions_FINAL.docx	Yes	No	Printable Only
Form and Instruction	CMS-10882	Medicare Prescription Payment Plan Participation Request Form	Exhibit 2_Election Request_FINAL.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10882	Part D Sponsor Notice to Acknowledge Acceptance of Election to the Medicare Prescription Payment Plan	Exhibit 3_Notice of Election Approval_FINAL.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10882	Part D Sponsor Notice for Failure to Make Payments under the Medicare Prescription Payment Plan	Exhibit 4_Notice of Failure to Pay_FINAL.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10882	Part D Sponsor Notice for Failure to Make Payments under Medicare Prescription Payment Plan â Notification of Termination of Participation in the Medicare Prescription Payment Plan	Exhibit 5_Notice of Involuntary Termination_FINAL.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10882	Part D Sponsor Notice of Voluntary Removal from the Medicare Prescription Payment Plan	Exhibit 6_Notice of Voluntary Termination_FINAL.docx	Yes	Yes	Fillable Printable

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: 1,065

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,065	1,065
Annual IC Time Burden (Hours)	21,300	21,300
Annual IC Cost Burden (Dollars)	8,686,462	8,686,462

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.