Retiree Drug Subsidy Payment Request Instructions

Forms and Documents

Document Name	Status
Justification for Collecting SSNs.doc Supplementary Document	2013-11-15
CMS-10170 - Supporting Statement. part A [rev 11-15-2013 by OSORA PRA].docx Supporting Statement A	2013-11-15

IC Document Collections

IC ID	Document Title	Status
8838	Private Sector -- Retiree Drug Subsidy (RDS) Payment Request and Instructions (CMS-10170) Instruction	Modified
188650	Public Respondents - Retiree Drug Subsidy (RDS) Payment Request and Instructions (CMS-10170) Instruction	Modified

ICR Details

OMB Control No: 0938-0977	ICR Reference No: 201311-0938-026
Status: Historical Active	Previous ICR Reference No: 200904-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: 20879
Title: Retiree Drug Subsidy Payment Request Instructions
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 without change	Conclusion Date: 02/14/2014
	Date Received in OIRA: 11/22/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2017	36 Months From Approved
Responses	4,500	0	0
Time Burden (Hours)	679,500	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and implementing regulations at 42 CFR ?423 Subpart R, Plan Sponsors (e.g., employers or unions) that offer prescription drug coverage to their qualifying covered retirees are eligible to receive a 28% tax-free subsidy for allowable drug costs. In order to receive the subsidy, a Plan Sponsor must submit required prescription drug cost data and certain other data to CMS.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1860 Name of Statute: null
   US Code: 42 USC 1395 W-132 Name of Law: Special Rules for employer sponsored programs
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 41931	07/12/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 61846	10/04/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Private Sector -- Retiree Drug Subsidy (RDS) Payment Request and Instructions (CMS-10170)	CMS-10170	Retiree Drug Subsidy Payment
Public Respondents - Retiree Drug Subsidy (RDS) Payment Request and Instructions (CMS-10170)	CMS-10170	Retiree Drug Subsidy Payment

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	4,500	0	0	0	0	4,500
Annual Time Burden (Hours)	679,500	0	0	0	0	679,500
Annual Cost Burden (Dollars)	0	0	0	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:

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Annual Cost to Federal Government: $20,600,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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Common Form ICR:  No

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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: 11/22/2013

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