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Federal forms, ICRs, and supporting documents

OMB control number

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

OMB 0938-0964 · HHS/CMS.

OMB 0938-0964

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.

The latest form for Medicare Prescription Drug Benefit Program - IRASA (CMS-10141) expires 2028-01-31 and is listed under ICR 202412-0938-003.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-10141 Model Precluded Provider LetterForm and Instruction
Form CMS-10141 Preparation and Issuance of Model Notices (section 423.120(c)(6))Form and Instruction
Form CMS-10141 3h - Exhibit G: Example of a Part D EOB (All Sections Included)Form and Instruction
Form CMS-10141 3g - Exhibit F: Example of Sections 5 and 6 (Information for Reference)Form and Instruction
Form CMS-10141 3f - Exhibit E: Example of Section 4 (Changes to the Formulary)Form and Instruction
Form CMS-10141 3e - Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs)Form and Instruction
Form CMS-10141 3d - Exhibit C: Example of Section 2 (Drug Payment Stages)Form and Instruction
Form CMS-10141 3c - Exhibit B: Examples of Section 1 (the List of Prescriptions)Form and Instruction
Form CMS-10141 3b - Exhibit A: Example Cover Page of the Model Part D EOBForm and Instruction
Form CMS-10141 3a - 2022 Model Part D Explanation of Benefits (All Sections Included)Form and Instruction
Form CMS-10141 Part C and D Model Precluded Provider LetterForm and Instruction
Form CMS-10141 Medicare Prescription Drug Benefit Program (Plans)Form and Instruction
CMS-10141 - Supporting Statement A__.docxSupporting Statement A
CMS-10141 - Supporting Statement A__.docxSupporting Statement A
Crosswalk 10141.pdfSupplementary Document
Crosswalk 10141.pdf Supplementary Document
Medicare Prescription Drug Benefit Program (Benes) Information collection
Utilization Management Committee and Health Equity 422.137 Information collection
Preparation and Issuance of Model Notices (section 423.120(c)(6)) Form and Instruction
Preparation and Issuance of Model Notices (section 423.120(c)(6)) Form and Instruction
Business Continuity Plans under 422.504(o) and 423.505(p) Information collection
State Eligibility Determinations (423.904(b)) and Reporting (423.910(d)) Information collection
Medicare Prescription Drug Benefit Program (Plans) Form and Instruction
Medicare Prescription Drug Benefit Program (Plans) Form and Instruction
Medicare Prescription Drug Benefit Program (Plans) Form and Instruction
Medicare Prescription Drug Benefit Program (Plans) Form and Instruction
Medicare Prescription Drug Benefit Program (Plans) Form and Instruction
Medicare Prescription Drug Benefit Program (Plans) Form and Instruction
Medicare Prescription Drug Benefit Program (Plans) Form and Instruction
Medicare Prescription Drug Benefit Program (Plans) Form and Instruction
Medicare Prescription Drug Benefit Program (Plans) Form and Instruction
Medicare Prescription Drug Benefit Program (Plans) Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202412-0938-003 Revision of a currently approved collection 2024-12-04
202302-0938-009 Revision of a currently approved collection 2023-02-22 Approved without change
202204-0938-002 Revision of a currently approved collection 2022-04-27 Approved without change
202110-0938-012 Revision of a currently approved collection 2021-11-09 Approved with change
202003-0938-008 Revision of a currently approved collection 2020-04-30 Comment filed on proposed rule and continue
201906-0938-001 Revision of a currently approved collection 2019-07-09 Approved with change
201812-0938-017 Revision of a currently approved collection 2018-12-21 Comment filed on proposed rule and continue
201803-0938-004 Revision of a currently approved collection 2018-05-09 Approved with change
201712-0938-003 Revision of a currently approved collection 2017-12-26 Comment filed on proposed rule and continue
201506-0938-007 Revision of a currently approved collection 2015-06-19 Approved with change
201312-0938-021 Revision of a currently approved collection 2013-12-27 Approved without change
201203-0938-004 No material or nonsubstantive change to a currently approved collection 2012-03-13 Approved without change
201008-0938-020 Revision of a currently approved collection 2010-08-30 Approved without change
200905-0938-002 Extension without change of a currently approved collection 2009-05-28 Approved with change
200901-0938-003 Revision of a currently approved collection 2009-01-14 Approved without change
200811-0938-004 Revision of a currently approved collection 2008-11-11 Preapproved
200609-0938-008 No material or nonsubstantive change to a currently approved collection 2006-09-29 Approved without change
200507-0938-010 New collection (Request for a new OMB Control Number) 2005-07-22 Approved with change

OMB Details

Medicare Prescription Drug Benefit Program (Benes)

Federal Enterprise Architecture: Health - Health Care Services