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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
CY 2011-Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
42 CFR 423.514
42 CFR 423.440
42 CFR 423.153
42 CFR 423.112
42 CFR 423.120
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
Applications for New Cost Plan Sponsors
30 day_2011 Cost formatted.pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
CMS-10137
Medicare Part D Application for New PACE Organizations
30 day_2011 PACE Part D.pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
CMS-10137
Applications for New Prescription Drug Plans (PDP) Sponsors
30 day_2011 PDP formatted.pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
CMS-10137
Part D Service Area Expansion Application
30 day_2011 SAE formatted.pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
CMS-10137
Applications for New Medicare Advantage - Prescription Drug Plans (MA-PD) Sponsors
30 day_2011MA-PD formatted.pdf
Yes
Yes
Fillable Fileable Signable
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:
453
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
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
453
0
-2
0
0
455
Annual IC Time Burden (Hours)
11,919
0
29
0
0
11,890
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Red line_2011 PDP formatted
Red line_2011 PDP formatted.doc
10/02/2009
Red line_2011 Cost formatted
Red line_2011 Cost formatted.doc
10/02/2009
Red line_2011 PACE Part D
Red line_2011 PACE Part D.doc
10/02/2009
Red line_2011 SAE formatted
Red line_2011 SAE formatted.doc
10/02/2009
Red line_2011MA-PD formatted
Red line_2011MA-PD formatted.doc
10/02/2009
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.