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Federal forms, ICRs, and supporting documents

Information Collection Request

Hospice Information for Medicare Part D Plans (CMS-10538)

ICR 202504-0938-003 · OMB 0938-1269 · Received in OIRA

Forms and Documents
Document
Name
Status
Form and Instruction
 Modified
Supporting Statement A
2025-05-12
Supplementary Document
2025-04-02
Supplementary Document
2025-04-02
IC Document Collections
IC ID
Document
Title
Status
214736 Modified
ICR Details
0938-1269 202504-0938-003
Received in OIRA 201809-0938-004
HHS/CMS CM-CPC
Hospice Information for Medicare Part D Plans (CMS-10538)
Reinstatement without change of a previously approved collection   No
Regular 05/13/2025
  Requested Previously Approved
36 Months From Approved
57,027 0
2,329 0
0 0
The Social Security Act in section 1861(dd) and Federal regulations in 42 CFR §418.106 and § 418.202(f) require hospice programs to provide individuals under hospice care with drugs and biologicals related to the palliation and management of the terminal illness as defined in the hospice plan of care. Medicare payment is made to the hospice for each day an eligible beneficiary is under the hospice's care, regardless of the amount of services provided on any given day. Because hospice care is a Medicare Part A benefit, drugs provided by the hospice and covered under the Medicare payment to the hospice program are not covered under Part D. The industry in conjunction with the National Council for Prescription Drug Programs, (NCPDP) developed a draft Medicare Part D Hospice Form to collect information necessary for the Part D sponsor to override a hospice prior authorization reject for beneficiaries enrolled in hospice. CMS made minor revisions to the NCPDP form to create this Standardized Form entitled Hospice Information for Medicare Part D Plans. This PRA submission is a request for approval of the standardized form available for use by Part D sponsors.
PL: Pub.L. 97 - 248 122 Name of Law: TEFRA
  
None
Not associated with rulemaking
  89 FR 101606 12/16/2024
90 FR 20166 05/12/2025
Yes
1
IC Title Form No. Form Name
Hospice Information for Medicare Part D Plans CMS-10538 Hospice Information for Medicare Part D Plans
  Total Request 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 57,027 0 0 0 -319,460 376,487
Annual Time Burden (Hours) 2,329 0 0 0 -29,045 31,374
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
Reduction in burden for this iteration, from 20,707 hours to 2,329 hours. This is due to a smaller number of Part D Parent organizations, as well as built-in efficiencies for facilitation of this information collection.
$785
No
    No
    No
No
No
No
No
Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
05/13/2025