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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EPOG
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
42 CFR 423.112
42 CFR 423.440
42 CFR 423.153
42 CFR 423.120
42 CFR 423.514
42 CFR 423.512
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-10137
Application for New PDP
CMS-10137 2008pdpappdraft110606 clean version.doc
Yes
Yes
Paper Only
Form and Instruction
CMS-10137
SAE Application
CMS-10137 Clean SAEApp2008_110706.doc
Yes
Yes
Paper Only
Form and Instruction
CMS-10137
Application for New Cost Plan
CMS-10137 CostPlanPartDApp2008_110606cleanversion.DOC
Yes
Yes
Paper Only
Form and Instruction
CMS-10137 EPOG
Application for EPOG
CMS-10137-EPOG DRAFT_2008_DirectMAPDApplication.clean.DOC
Yes
Yes
Paper Only
Form and Instruction
CMS-10137
Application for New Employer
CMS-10137 EPOG DRAFT_2008_DirectPDPApplication.clean.doc
Yes
Yes
Paper Only
Form and Instruction
CMS-10137
Application for New MA-PD
CMS-10137 MAPDPartDApp2008_110606clean version.DOC
Yes
Yes
Paper Only
Form and Instruction
CMS-10137 EPOG
Application for New EPOG PDP
CMS-10137-EPOG Draft_EGWP New PDP_app_11.08.06.clean.doc
Yes
Yes
Paper Only
Form and Instruction
CMS-10137 EPOG
Application for Existing PDP
CMS-10137-EPOG Draft_EGWP_Existing PDP_app_11.08.06.clean.doc
Yes
Yes
Paper Only
Form and Instruction
CMS-10137 EPOG
Application for EPOG Cost Plans
CMS-10137-EPOG EGWPCost_DRAFT 11.08.06.clean.doc
Yes
Yes
Paper Only
Form and Instruction
CMS-10137
SAE Application
DraftSAEApp2008_120806.doc
Yes
Yes
Paper Only
Form and Instruction
CMS-10137
Application for New PDP
Draft2008pdpapp120706.doc
Yes
Yes
Paper Only
Form and Instruction
CMS-10137
Application for New MA-PD
DraftMAPDPartDApp2008_120706 (2).doc
Yes
Yes
Paper Only
Form and Instruction
CMS-10137
Application for New Cost Plan
DraftCostPlanPartDApp2008_120706 (2).doc
Yes
Yes
Paper Only
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:
216
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:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
216
115
0
0
0
101
Annual IC Time Burden (Hours)
5,316
1,488
0
0
0
3,828
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
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.