Part C and Part D Medicare Prescription Payment Plan Model Documents (CMS-10882) - IRA

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10882 Likely to Benefit Notice_ Korean	Form and Instruction	Modified	Available
Form CMS-10882 Likely to Benefit Notice_ Vietnamese	Form and Instruction	Modified	Available
Form CMS-10882 Likely to Benefit Notice_ Chinese	Form and Instruction	Modified	Available
Form CMS-10882 Part D Sponsor Notice of Participation Renewal in the Medicare Prescription Payment Plan	Form and Instruction	Modified	Available
Form CMS-10882 Part D Sponsor Notice of Voluntary Removal from the Medicare Prescription Payment Plan	Form and Instruction	Modified	Available
Form 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	Form and Instruction	Modified	Available
Form CMS-10882 Part D Sponsor Notice for Failure to Make Payments under the Medicare Prescription Payment Plan	Form and Instruction	Modified	Available
Form CMS-10882 Part D Sponsor Notice to Acknowledge Acceptance of Election to the Medicare Prescription Payment Plan	Form and Instruction	Modified	Available
Form CMS-10882 Medicare Prescription Payment Plan Participation Request Form	Form and Instruction	Modified	Available
Form CMS-10882 Likely to Benefit Instructions	Form and Instruction	Modified	Available
Form CMS-10882 Likely to Benefit Notice_ Spanish	Form and Instruction	Modified	Available
Form CMS-10882 Likely to Benefit Notice	Form and Instruction	Modified	Available
Form CMS-10882 MPPP Model Notices Programming	Form and Instruction	Modified	Repair queued
M3P 30 Day Comment Grid (10882) FINAL.pdf	Supplementary Document	Uploaded 2025-09-11	Available
Paytient Comment on Medicare Prescription Payment Plan Guidance.pdf	Public Comments	Uploaded 2025-09-02	Available
[EXTERNAL] ICR Comment [0938-1475] [202507-0938-023] MPPP Model Documents.pdf	Public Comments	Uploaded 2025-09-02	Available
UHC Comments - M3P Model Documents_8.27.2025.pdf	Public Comments	Uploaded 2025-09-02	Available
[EXTERNAL] ICR Comment [0938-1475] [202507-0938-023] MPPP Model Documents Part 2.pdf	Public Comments	Uploaded 2025-09-02	Available
[EXTERNAL] ICR Comment_ OMB Control Number_ OMB 0938-1475 Collection Title_ Medicare Prescription Payment Plan Model Documements.pdf	Public Comments	Uploaded 2025-09-02	Available
2026_M3P Election Form_Template_ (swap read-sign with AOR).docx	Public Comments	Uploaded 2025-08-08	Available
PC_202507-0938-023_080825_025920_1.pdf	Public Comments	Uploaded 2025-08-08	Available
CMS-10882_Supporting Statement A_2025-.docx	Supporting Statement A	Uploaded 2025-07-28	Available
CMS-10882_Supporting Statement A_2025-.docx	Supporting Statement A	Uploaded 2025-07-28	Missing upstream
60-day comments.pdf	Public Comments	Uploaded 2025-07-09	Repair queued
Response to Public Comments (CMS-10882).xlsx	Supplementary Document	Uploaded 2025-07-23	Available
Response to Public Comments (CMS-10882).xlsx	Supplementary Document	Uploaded 2025-07-23	Available
CMS-10882_ Comment_Crosswalk.docx	Supplementary Document	Uploaded 2025-09-11	Available
CMS-10882_ Comment_Crosswalk.docx	Supplementary Document	Uploaded 2025-07-23	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
267917	MPPP Model Notices Programming	Form and Instruction	Modified	Likely to Benefit Notice_ Korean
267917	MPPP Model Notices Programming	Form and Instruction	Modified	Likely to Benefit Notice_ Vietnamese
267917	MPPP Model Notices Programming	Form and Instruction	Modified	Likely to Benefit Notice_ Chinese
267917	MPPP Model Notices Programming	Form and Instruction	Modified	Part D Sponsor Notice of Participation Renewal in the Medicare Prescription Payment Plan
267917	MPPP Model Notices Programming	Form and Instruction	Modified	Part D Sponsor Notice of Voluntary Removal from the Medicare Prescription Payment Plan
267917	MPPP Model Notices Programming	Form and Instruction	Modified	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
267917	MPPP Model Notices Programming	Form and Instruction	Modified	Part D Sponsor Notice for Failure to Make Payments under the Medicare Prescription Payment Plan
267917	MPPP Model Notices Programming	Form and Instruction	Modified	Part D Sponsor Notice to Acknowledge Acceptance of Election to the Medicare Prescription Payment Plan
267917	MPPP Model Notices Programming	Form and Instruction	Modified	Medicare Prescription Payment Plan Participation Request Form
267917	MPPP Model Notices Programming	Form and Instruction	Modified	Likely to Benefit Instructions
267917	MPPP Model Notices Programming	Form and Instruction	Modified	Likely to Benefit Notice_ Spanish
267917	MPPP Model Notices Programming	Form and Instruction	Modified	Likely to Benefit Notice
267917	MPPP Model Notices Programming	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1475	ICR Reference No: 202507-0938-023
Status: Active	Previous ICR Reference No: 202409-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Part C and Part D Medicare Prescription Payment Plan Model Documents (CMS-10882) - IRA
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: 12/22/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/29/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2028	36 Months From Approved	12/31/2025
Responses	39,514,987	0	1,065
Time Burden (Hours)	135,080	0	21,300
Cost Burden (Dollars)	43,841,218	0	8,686,462

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Abstract: The purpose of this information collection request for the approval of model documents for the Medicare Prescription Drug Program (Part D) is to meet the requirements of Section 11202 of the Inflation Reduction Act of 2022, Public L. 117-169 (IRA), which established the Medicare Prescription Payment Plan Program. Under this program, MA Organizations offering Part D coverage and Part D sponsors are required to offer enrollees the option to pay their Part D cost sharing in monthly amounts spread out over the plan year based on the formula described in section 1860D-2(b)(2)(E)(iv) of the Act. There are several education and outreach requirements for plan sponsors related to implementation of this program. The proposed documents in this information collection are designed to assist Part D plan sponsors and MA organizations in complying with Sections 1860D-2(b)(2)(E)(v)(II) – (IV) of the Social Security Act (the Act), which set forth the education and outreach responsibilities for Part D sponsors and MA organizations for this program. CMS has developed the six materials in the attached package as model notices to provide standardized and consistent language for potential and active program participants, regardless of which Part D plan they may be enrolled in. CMS will require Part D plans to disseminate these notices, as appropriate, to Part D enrollees to fulfill the requirements of the Sections 1860D-2(b)(2)(E)(v)(II) – (IV) of the Act. The six model notices and their related burden are accounted for in this PRA package. By providing these model notices, CMS is providing standardized messaging for all Part D beneficiaries and reducing administrative burden on Part D sponsors and MA organizations.

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Authorizing Statute(s): PL: Pub.L. 117 - 169 11202 Name of Law: Inflation Reduction Act of 2022
  

Citations for New Statutory Requirements: None

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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:
	90 FR 20304	05/13/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 35529	07/28/2025
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
MPPP Model Notices Programming	CMS-10882, CMS-10882, CMS-10882, CMS-10882, CMS-10882, CMS-10882, CMS-10882, CMS-10882, CMS-10882, CMS-10882, CMS-10882, CMS-10882	Likely to Benefit Notice ,   Likely to Benefit Notice_ Spanish ,   Likely to Benefit Instructions ,   Medicare Prescription Payment Plan Participation Request Form ,   Part D Sponsor Notice to Acknowledge Acceptance of Election to the Medicare Prescription Payment Plan ,   Part D Sponsor Notice for Failure to Make Payments under the Medicare Prescription Payment Plan ,   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 ,   Part D Sponsor Notice of Voluntary Removal from the Medicare Prescription Payment Plan ,   Part D Sponsor Notice of Participation Renewal in the Medicare Prescription Payment Plan ,   Likely to Benefit Notice_ Chinese ,   Likely to Benefit Notice_ Vietnamese ,   Likely to Benefit Notice_ Korean

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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	39,514,987	1,065	0	39,513,922	0	0
Annual Time Burden (Hours)	135,080	21,300	0	113,780	0	0
Annual Cost Burden (Dollars)	43,841,218	8,686,462	0	35,154,756	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Burden has increased due to added burden and revised burden associated with the Medicare Prescription Payment Plan that was not accounted for in previous PRA packages, including annual burden for Part D plan sponsors to comply with requirements to mail billing statements, annual burden for Part D plan sponsors to report their program-specific PCN starting with “MPPP” to CMS, one-time burden for Part D plan sponsors to set up systems for participation renewal, one-time burden for Part D plan sponsors to develop the Notice of Participation Renewal, and annual burden for Part D plan sponsors to update their systems to reflect changes to the likely to benefit criteria. We also added one-time beneficiary burden to complete the opt-out process and annual burden for pharmacies to provide the Likely to Benefit Notice.

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Annual Cost to Federal Government: $2,826

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: 07/29/2025

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