Information Collection

State, Local, or Tribal Governments - Creditable Coverage Disclosure to CMS OnLine Form and Instructions

IC 46153 under ICR 202507-0938-007 · OMB 0938-1013.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1013 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10198 State, Local, or Tribal Governments - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Form and Instruction
Form CMS-10198 Creditable Coverage Disclosure to CMS State, Local, or Tribal Governments - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Form and Instruction
Form CMS-10198 CC Form (screen shot) State, Local, or Tribal Governments - Creditable Coverage Disclosure to CMS OnLine Form and Instructions	Form
CMS-10198 Creditable Coverage Disclosure to CMS CC Disclosure to CMS Instructions and Screen Shots.docx	Form and Instruction
CMS-10198 Creditable Coverage Disclosure to CMS CC Disclosure to CMS Instructions and Screen Shots.docx	Form and Instruction
CMS-10198 CC Form (screen shot) CCOnlinePageView.pdf	Form
CMS-10198 CC Form (screen shot) CCOnlinePageView.pdf	Form

IC Title:

State, Local, or Tribal Governments - Creditable Coverage Disclosure to CMS OnLine Form and Instructions

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.56e

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10198				Yes	Yes	Fillable Printable
Form	CMS-10198				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 58

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	58	9	49
Annual IC Time Burden (Hours)	5	1	4
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.

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