View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-1410
ICR Reference No:
202206-0938-002
Status:
Active
Previous ICR Reference No:
202201-0938-009
Agency/Subagency:
HHS/CMS
Agency Tracking No:
CM-CPC
Title:
Dual Eligible Special Needs Plan Contract with the State Medicaid Agency (CMS-10796)
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
08/01/2022
Retrieve Notice of Action (NOA)
Date Received in OIRA:
06/01/2022
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
08/31/2025
36 Months From Approved
Responses
525
0
0
Time Burden (Hours)
22,432
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
Medicare Advantage (MA) organizations with D-SNPs and States use the information in the contract to provide benefits, or arrange for the provision of Medicaid benefits, to which an enrollee is entitled. CMS reviews the D-SNP contract with the State Medicaid agency to ensure that it meets the requirements at ยง 422.107.
Authorizing Statute(s):
PL:
Pub.L. 115 - 123 50311(b)
Name of Law: Bipartisan Budget Act of 2018
PL:
Pub.L. 108 - 173 1859(b)(6) and 1859(f)(3)(D)
Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
0938-AU30
Final or interim final rulemaking
87 FR 27704
05/09/2022
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Dual Eligible Special Needs Plan Contract with the State Medicaid Agency
CMS-10796, CMS-10796, CMS-10796
D-SNP State Medicaid Agency(ies) Contract(s): Attestations
,
Appendix B - D-SNP State Medicaid Agency Contract Matrix.docx
,
Appendix C - Special Needs Plan (SNP) Contract Status Review Matrix
ICR Summary of Burden
Total Approved
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
525
0
0
525
0
0
Annual Time Burden (Hours)
22,432
0
0
22,432
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Changing Regulations
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
This is a new information collection request.
Annual Cost to Federal Government:
$169,821
Does this IC contain surveys, censuses, or employ statistical methods?
No
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
No
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
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?
No
Agency Contact:
Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov
Common Form ICR:
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:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(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;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
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.
Certification Date:
06/01/2022
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