Creditable Coverage Disclosure to CMS OnLine Form and Instructions (CMS-10198)

OMB 0938-1013

Information collection requirements will ensure that entities that currently provide prescription drug benefits to any Medicare Part D eligible individual disclose to CMS whether the prescription drug benefit that they offer is creditable coverage. The disclosure is required to be provide annually and upon any change that affects whether the coverage is creditable prescription drug coverage. This collection also provides creditable coverage disclosure instructions for entities complying with these infromation collection request.

The latest form for Creditable Coverage Disclosure to CMS OnLine Form and Instructions (CMS-10198) expires 2020-12-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10198 Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form and Instruction
Form CMS-10198 Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form and Instruction
CMS-10198 Creditable Coverage Supporting Statement A.docx Supporting Statement A
State, Local, or Tribal Governments - Creditable Coverage Disclosure to CMS OnLine Form and Instructions
Private Sector - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form and Instruction
Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions Form and Instruction

All Historical Document Collections

202103-0938-013 Approved without change	Reinstatement without change of a previously approved collection	2021-04-01
201702-0938-018 Approved with change	Extension without change of a currently approved collection	2017-02-27
201604-0938-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-04-05
201312-0938-006 Approved without change	Reinstatement with change of a previously approved collection	2013-12-06
200911-0938-003 Approved without change	Extension without change of a currently approved collection	2009-11-25
200706-0938-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2007-06-12
200611-0938-010 Approved without change	New collection (Request for a new OMB Control Number)	2006-11-22

OMB Details

Federal - Creditable Coverage Disclosure to CMS OnLine Form and Instructions

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-10198	Creditable Coverage Disclosure to CMS	Fillable Printable	Form and instruction
Form CMS-10198	CC Form (screen shot)	Fillable Printable	Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.