Document Name Document Type
Form CMS-10882 MPPP Model Notices Programming Form and Instruction
CMS-10882 Likely to Benefit Notice Exhibit 1_Likely to Benefit Notice_ENG_508_ACheccked081421.docx Form and Instruction
CMS-10882 Likely to Benefit Notice Exhibit 1_Likely to Benefit Notice_ENG_508_ACheccked081421.docx Form and Instruction
CMS-10882 Likely to Benefit Notice_ Spanish Exhibit 1.2_Likely to Benefit Notice_SPA_508_AChecked081424.docx Form and Instruction
CMS-10882 Likely to Benefit Notice_ Spanish Exhibit 1.2_Likely to Benefit Notice_SPA_508_AChecked081424.docx Form and Instruction
CMS-10882 Likely to Benefit Instructions Exhibit 1.3_Likely to Benefit Instructions_508_AChecked081424.docx Form and Instruction
CMS-10882 Likely to Benefit Instructions Exhibit 1.3_Likely to Benefit Instructions_508_AChecked081424.docx Form and Instruction
CMS-10882 Medicare Prescription Payment Plan Participation Request Exhibit 2_Election Request_FINAL.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_FINAL.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_FINAL_Revised.docx Form and Instruction
CMS-10882 Part D Sponsor Notice for Failure to Make Payments under Exhibit 4_Notice of Failure to Pay_FINAL_Revised.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 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_FINAL.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

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IC Title:	MPPP Model Notices Programming	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10882	Likely to Benefit Notice	Exhibit 1_Likely to Benefit Notice_ENG_508_ACheccked081421.docx	Yes	No	Printable Only
Form and Instruction	CMS-10882	Likely to Benefit Notice_ Spanish	Exhibit 1.2_Likely to Benefit Notice_SPA_508_AChecked081424.docx	Yes	No	Printable Only
Form and Instruction	CMS-10882	Likely to Benefit Instructions	Exhibit 1.3_Likely to Benefit Instructions_508_AChecked081424.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_Revised.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10882	Part D Sponsor Notice for Failure to Make Payments under Medicare Prescription Payment Plan – 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 %

	Approved	Previously Approved
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

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.

MPPP Model Notices Programming

The Medicare Advantage and Prescription Drug Programs: Part C and Part D Medicare Prescription Payment Plan Model Documents (CMS-10882) - IRA

OMB: 0938-1475

IC ID: 267917

View Information Collection (IC)