CY 2012-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⚠️ Notice: This information collection may be referencing outdated material.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 2012-Applications for Medicare Part D Plans; PDP Plans, MA-PD Plans, Cost Plans, PACE Organizations, SAE and EGWP Form and Instruction
CMS-10137 Application_for_New_PACE_Plan 2012_Application_for_New_PACE_Plan.pdf Form and Instruction
CMS-10137 2013 Application for New Cost Plan 2013 Application for New Cost Plan.pdf Form and Instruction
CMS-10137 2013 Application for New Prescription Drug Plan (PDP) 2013 Application for New Prescription Drug Plan (PDP)_clean_30day.pdf Form and Instruction
CMS-10137 2013 Application for PDP and MA-PD Service Area Expansio 2013 Application for PDP and MA-PD Service Area Expansion (SAE).pdf Form and Instruction
CMS-10137 2013 New Medicare Advantage Prescription Drug Plan (MA-P 2013 New Medicare Advantage Prescription Drug Plan (MA-PD).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	CY 2012-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	2013 Application for PDP and MA-PD Service Area Expansion	2013 Application for PDP and MA-PD Service Area Expansion (SAE).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10137	2013 New Medicare Advantage Prescription Drug Plan (MA-PD	2013 New Medicare Advantage Prescription Drug Plan (MA-PD).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10137	Application_for_New_PACE_Plan	2012_Application_for_New_PACE_Plan.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10137	2013 Application for New Cost Plan	2013 Application for New Cost Plan.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10137	2013 Application for New Prescription Drug Plan (PDP)	2013 Application for New Prescription Drug Plan (PDP)_clean_30day.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 178	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	178	-234	117	295
Annual IC Time Burden (Hours)	2,322	178	-1,432	3,576
Annual IC Cost Burden (Dollars)	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.