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OMB Control No: 0938-0935	ICR Reference No: 201410-0938-002
Status: Historical Active	Previous ICR Reference No: 201310-0938-014
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 (CMS-10237)
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: 11/24/2014
	Date Received in OIRA: 10/03/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2017	36 Months From Approved	04/30/2017
Responses	566	0	566
Time Burden (Hours)	22,625	0	22,955
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:
	79 FR 40105	07/11/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 59773	10/03/2014
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 Agency Discretion
Annual Number of Responses	566	566	0
Annual Time Burden (Hours)	22,625	22,955	-330
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: Yes

Burden Reduction Due to: Changing Forms

Short Statement: Currently approved Initial Application hr 3,432 Revised Initial Application hr -3,102 Program Change -330 hr There is a decrease in burden hours for 2016 as described below (decreased by 4.5 hours): CMS removed the following upload requirements in section 3.9 CMS Provider Participation Contracts & Agreements and 3.10 Contracts for Administrative & Management Services. The upload requirements were removed from section 3.9 because CMS will no longer request a sample of Provider Participation Contracts & Agreements for review. CMS will still require applicants to complete the attestations in this section. CMS continues to hold the MAO responsible for the compliance of its providers and subcontractors with all contractual, legal, regulatory, and operational obligations. The upload requirements were removed from section 3.10 because CMS will no longer be reviewing Contracts for Administrative and Management Services. This applies only to the Part C review of application materials. The Part D application review process will continue to review these documents in its review of administrative and management services. CMS also removed attestation #5 under section 3.10 because it related to the upload requirements that are now removed. HSD tables, instructions and exceptions process: Slight decrease in burden as we removed the requirement for the applicants to record the CMS certification number (CCN) on the MA facility table. The HSD Instructions document was revised to no longer include instructions on obtaining the CCN number. Decrease in burden .5 hours.

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

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