CY 2011-Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP

Applications for Medicare Part D plans: PDP Plans, MA-PD Plans, Cost Plans, PACE organizations, SAE and EGWP

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0936 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10137 CY 2011-Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP Form and Instruction
CMS-10137 Applications for New Cost Plan Sponsors 30 day_2011 Cost formatted.pdf Form and Instruction
CMS-10137 Medicare Part D Application for New PACE Organizations 30 day_2011 PACE Part D.pdf Form and Instruction
CMS-10137 Applications for New Prescription Drug Plans (PDP) Spons 30 day_2011 PDP formatted.pdf Form and Instruction
CMS-10137 Part D Service Area Expansion Application 30 day_2011 SAE formatted.pdf Form and Instruction
CMS-10137 Applications for New Medicare Advantage - Prescription D 30 day_2011MA-PD formatted.pdf Form and Instruction
Red line_2011 PDP formatted.doc Red line_2011 PDP formatted IC Document
Red line_2011 Cost formatted.doc Red line_2011 Cost formatted IC Document
Red line_2011 PACE Part D.doc Red line_2011 PACE Part D IC Document
Red line_2011 SAE formatted.doc Red line_2011 SAE formatted IC Document
Red line_2011MA-PD formatted.doc Red line_2011MA-PD formatted IC Document

Information Collection (IC) Details

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	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

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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	453	-2	455
Annual IC Time Burden (Hours)	11,919	29	11,890
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.