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OMB Control No: 0938-0935	ICR Reference No: 201310-0938-014
Status: Historical Active	Previous ICR Reference No: 201211-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: 20764
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 without change	Conclusion Date: 04/21/2014
	Date Received in OIRA: 10/31/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2017	36 Months From Approved	12/31/2015
Responses	566	0	566
Time Burden (Hours)	22,955	0	21,581
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:
	78 FR 38986	06/28/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 61846	10/04/2013
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 Application and 1876 Cost Plan Expansion Application	CMS-10237, CMS-10237, CMS-10237, CMS-10237	, , ,

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	566	566	0
Annual Time Burden (Hours)	22,955	21,581	1,374
Annual Cost Burden (Dollars)	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: While there is an increase in burden hours from the 2014 contract year (CY) by +1,374, the 30-day package's revision to section 3.11 of the application does not increase our burden estimate. The change is described below. PART C -MEDICARE ADVANTAGE and 1876 COST PLAN EXPANSION APPLICATION: Based on current internal review of the CY2014 burden estimates we are revising them for CY2015. Specifically, an additional 15 hours of burden was added to complete the Initial CCP, PFFS network, EGWP application and an additional 2 hours of burden was added to complete the SAE CCP, PFFS network, EGWP applications. The increase in burden in not due to any statutory changes, regulatory changes or public comments. Instead the increase reflects a more realistic timeframe on how long it takes an applicant to complete the applications mentioned above. CY2015 changes to application: 1. CMS added new attestations to section 3.1. Waiver request will need to be completed if the applicant attests "no" to the new attestation (section 3.1 #3). 2. CMS added attestations after the 60 day comment period for section 3.11. Attestations are related to admitting privileges of contracted providers at contracted facilities and pertaining to delivery of transplant services. CY2015 changes to application after 60 day comment period by: 1. Removing Section IV of Partial County Justification referring to Provider Network Assessment for partial counties because this section no longer applies due to the HPMS automated review of partial county networks. 2. Removing Section 4.14 Partial County Network Assessment Table because this table no longer applies due to the HPMS automated review of partial county networks. PART C -MEDICARE ADVANTAGE and 1876 COST PLAN EXPANSION APPLICATION-Appendix 1 Special Needs Plan Proposal: 1.) Removing the upload requirement for the D-SNP State Medicaid Agency Contract Negotiation Status Document from the application. 2.) Removing attestation #6, "Provide the State Medicaid contract begin date, under the D-SNP State Medicaid Agency Contracts Attestation section." 3.) Removing attestation #7, "Provide the State Medicaid contract end date, under the D-SNP State Medicaid Agency Contracts Attestation section." 4.) Removing attestation #8, "Does the applicant want the State Medicaid Agency Contract to be reviewed to determine if it qualifies as a FIDE SNP for the contract period(s) identified in numbers 6 and 7", as it similar to Attestation #2 which says "Applicant wishes the contract with the State Medicaid Agency(ies) to be reviewed to determine if it qualifies as a fully integrated dual eligible SNP (FIDE)." 5.) Removing approximately 240 attestations from the Model of Care section. All of the changes to Appendix 1 Special Needs Plan Proposal decrease burden by approximately 1 hour.

Annual Cost to Federal Government: $1,770,600

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

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

View ICR - OIRA Conclusion