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OMB Control No: 0938-0935	ICR Reference No: 201211-0938-007
Status: Historical Active	Previous ICR Reference No: 201111-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Advantage Application - Part C and 1876 Cost Plan Expansion Application regulations under 42 CFR 422 subpart K & 417.400
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/20/2012
	Date Received in OIRA: 11/21/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	36 Months From Approved	01/31/2015
Responses	566	0	378
Time Burden (Hours)	21,581	0	13,296
Cost Burden (Dollars)	0	0	0

Abstract: In order to provide health benefits to Medicare beneficiaries under the Medicare Advantage Program and/or the 1876 Cost Plan, applicant must meet regulatory requirements to enter into a contract with CMS, or to continue to contract with CMS. The revised Part C application is created to capture the applicants' information.

Authorizing Statute(s): PL: Pub.L. 110 - 275 161 Name of Law: Provisions relating to Part C
   US Code: 42 USC 1395mm
   PL: Pub.L. 108 - 173 1857 Name of Law: Medicare Advantage

Citations for New Statutory Requirements: None

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

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 40064	07/06/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 62241	10/12/2012
Did the Agency receive public comments on this ICR? Yes

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)	CMS-10237, CMS-10237, CMS-10237, CMS-10237	, , ,

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion	Change Due to Adjustment in Estimate
Annual Number of Responses	566	378	0	188
Annual Time Burden (Hours)	21,581	13,296	8,285	0
Annual Cost Burden (Dollars)	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Increase Burden Hours per Special Needs Plan (SNP) application: For CY2014, CMS added one (1) new matrix to facilitate the contract review process for Fully-Integrated Dual Eligible (FIDE) Special Needs Plans (SNPs). Revisions were also made to the End Stage Renal Disease (ESRD) Waiver to ensure the collection of required information from SNPs applying for this waiver. An additional two (2) hours of burden was added to the SNP Medicare Advantage (MA) and SNP Service Area Expansion (SAE) applications. CMS also added two templates and an attestation to request that Medicare Advantage Organizations (MAOs) describe how enrollees will have equal access to specified tiered medical benefits. An additional 12 hours of burden was added to the initial MA Applications. Increase in Overall Burden of Hours and Respondents: Although seven (7) contract attestations and three (3) templates were removed as a part of a lean process improvement to collect fewer documents from the applicants and require less review by CMS staff, the overall burden hours increased because of the increase in the expected number of respondents and the addition of matrices, templates, and attestations. An internal assessment of the number of respondents resulted in a higher projection for CY 2014.

Annual Cost to Federal Government: $948,400

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]? Yes

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

Agency Contact: William Parham 4107864669

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