View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0938-0977	ICR Reference No: 202008-0938-003
Status: Historical Active	Previous ICR Reference No: 201702-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Retiree Drug Subsidy Payment Request Instructions (CMS-10170)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/30/2021
	Date Received in OIRA: 08/17/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2024	36 Months From Approved
Responses	2,159	0	0
Time Burden (Hours)	326,009	0	0
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	2,159	-323	2,482
Annual Time Burden (Hours)	326,009	-48,773	374,782
Annual Cost Burden (Dollars)	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: The total burden is adjusted from 336,428 hr to 326,009 hr due to a reduction in RDS sponsor enrollment.

Annual Cost to Federal Government: $10,336,720

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. Yes

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. Yes

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: Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov

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