Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
This script is used to control the display of information in this page.
Display additional information by clicking on the following:
All
Brief and OIRA conclusion
Abstract/Justification
Legal Statutes
Rulemaking
FR Notices/Comments
IC List
Burden
Misc.
Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-0964
ICR Reference No:
202003-0938-008
Status:
Historical Inactive
Previous ICR Reference No:
201906-0938-001
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CM-CPC
Title:
Comprehensive Addiction and Recovery Act of 2016 (CARA) / Medicare Prescription Drug Benefit Program (CMS-10141)
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Comment filed on proposed rule and continue
Conclusion Date:
05/14/2020
Retrieve Notice of Action (NOA)
Date Received in OIRA:
04/30/2020
Terms of Clearance:
Terms of the previous clearance remain in effect. OMB files this comment in accordance with 5 CFR 1320.11( c ). This OMB action is not an approval to conduct or sponsor an information collection under the Paperwork Reduction Act of 1995. This action has no effect on any current approvals. If OMB has assigned this ICR a new OMB Control Number, the OMB Control Number will not appear in the active inventory. For future submissions of this information collection, reference the OMB Control Number provided. OMB is withholding approval at this time. Prior to publication of the final rule, the agency should provide a summary of any comments related to the information collection and their response, including any changes made to the ICR as a result of comments. In addition, the agency must enter the correct burden estimates.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
11/30/2021
36 Months From Approved
01/31/2022
Responses
625,627,848
0
625,627,848
Time Burden (Hours)
8,683,706
0
8,683,706
Cost Burden (Dollars)
5,733,706
0
5,733,706
Abstract:
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. Under CMS-4182-P (RIN 0938-AT08), CMS will make the Preclusion List available to Part D sponsors. The Part D sponsors will perform system programming to maintain the Preclusion List in order to reject a pharmacy claim (or deny a beneficiary request for reimbursement) for a Part D drug that is prescribed by an individual on the Preclusion List. CMS will create and disseminate model notices to the prescribers to notify them of their existence on the Preclusion List, while the Part D sponsors will create and disseminate model notices to the Medicare beneficiaries to notify them that the pharmacy claim is being rejected or denied due to the prescriber’s existence on the Preclusion List.
Authorizing Statute(s):
Statute at Large:
18 Stat. 1860
PL:
Pub.L. 108 - 173 101
Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
Citations for New Statutory Requirements:
PL: Pub.L. 108 - 173 101 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
0938-AT97
Proposed rulemaking
85 FR 9002
02/18/2020
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
85 FR 9002
02/18/2020
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
7
IC Title
Form No.
Form Name
Preparation and Issuance of Model Notices (section 423.120(c)(6))
Business Continuity Plans under 422.504(o) and 423.505(p)
CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141
Compensation Certification to be Completed by All Organizations
,
Compensation Structure for Plans
,
Covered Agent Information Sheet
,
Compensation Structure for Writing Agents by Contract/PBP Number
,
Compensation Certification to be Completed by Any Organization with Renewal Commission
,
Compensation Structure for Writing Agents
Creation of Model Notices (Plans) (section 423.120(c)(6))
CMS-10141, CMS-10141, CMS-10141
Initial Notice Sent to Potentially At-Risk Beneficiaries
,
Second Notice Sent to Beneficiary Designating At-Risk Status
,
Alternate Second Notice Sent to Beneficiary Not Considered At-Risk
Medicare Prescription Drug Benefit Program (Benes)
Medicare Prescription Drug Benefit Program (Plans)
CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141, CMS-10141
Model Part D Explanation of Benefits
,
Exhibit A: Example Cover Page of the Model Part D EOB
,
Exhibit B: Examples of Section 1 (the List of Prescriptions)
,
Exhibit C: Example of Section 2 (Drug Payment Stages)
,
Exhibit D: Example of Section 3 (Amounts and Definitions for TrOOP and Total Drug Costs)
,
Exhibit E: Example of Section 4 (Changes to the Formulary)
,
Exhibit F: Example of Sections 5 and 6 (Information for Reference)
,
Exhibit G: Example of a Part D EOB (All Sections Included)
State Eligibility Determinations (423.904(b)) and Reporting (423.910(d))
System Programming (Plans) (section 423.120(c)(6))
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:
This 2020 iteration proposes non-rule changes along with changes associated with a proposed rule (CMS-4190-P; RIN 0938-AT97) that published in the Federal Register on February 18, 2020 (85 FR 9002). See section 15 of the Supporting Statement for details.
Annual Cost to Federal Government:
$744
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
Agency Contact:
Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov
Common Form ICR:
No
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:
04/30/2020