Medicare Advantage Applications - Part C

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
2009appcommentmatrix-30-day- Masterlist.xls	Supplementary Document	Uploaded 2008-01-11	Available
2009Masterlist.xls	Supplementary Document	Uploaded 2007-10-10	Available
Highlevel-SummaryChanges 2008 to 2009 Part C applications.doc	Supplementary Document	Uploaded 2008-01-11	Available
12-27-07 EPOG MAO Applications_High level summary of changes_Final.doc	Supplementary Document	Uploaded 2007-12-27	Available
CMS Final 2009 Supporting Statement 122107_OSORA 122107 DQPM.DOC	Supporting Statement A	Uploaded 2008-01-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8785	Medicare Advantage Applications - Part C	Other-redline	Modified

ICR Details

OMB Control No: 0938-0935	ICR Reference No: 200801-0938-004
Status: Historical Active	Previous ICR Reference No: 200707-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Advantage Applications - Part C
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: 01/14/2008
	Date Received in OIRA: 01/11/2008
Terms of Clearance: Terms of Clearance: This collection is approved under the following terms of clearance: Upon publishing a new 60-day and 30-day Federal Register Notice, CMS will provide the public and OMB with a supplemental document that crosswalks all changes (technical and substantive) made to the revised ICR. The document should include an explanation of each change from the previous approval, the reason why the change is necessary and the citation or reference to the statute, regulation or guidance document that support the need for the change. The crosswalk should also address an increase or decrease in burden for each change.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2011	36 Months From Approved	01/31/2011
Responses	241	0	220
Time Burden (Hours)	5,858	0	5,580
Cost Burden (Dollars)	0	0	0

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Abstract: Health plans must meet regulatory requirements to enter into a contract with CMS; in order to provide health benefits to Medicare beneficiaries. The revised MA applications are the collection receptacles required.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 1857 Name of Law: Medicare Advantage
   PL: Pub.L. 108 - 173 1857 Name of Law: Contracts with Medicare+Choice Organizations
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 38601	07/13/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 58096	10/12/2007
Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

IC Title	Form No.	Form Name
Medicare Advantage Applications - Part C	CMS-10214, CMS-10214, CMS-10237	Medicare Advantage Prescription Drug Benefit ,   2009 Initial App for Employer/Union Direct Contract PFFS MA Organization ,   Medicare Advantage Master Application

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ICR Summary of Burden

table that charts list 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	241	220	0	21	0	0
Annual Time Burden (Hours)	5,858	5,580	0	278	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: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: It is expected that multiple applications from individual respondents will result in minimal additional cost to the government. CMS encouraged plans to submit a Notices of Intent (NOI). The NOIs allows organizations to provide CMS an early estimate of the applications they intend to submit. NOIs will be received and entered into our Health Plan Management System (HPMS). As a result, the total burden will be increased slightly to provide a more accurate depiction of the number of applications CMS expects to receive. Finally, for 2009 contracts awarded in September 2009; will renew annually; unless otherwise notified by CMS. Organizations holding 2008 contracts will not need to re-apply in 2009 and may continue providing services to beneficiaries unless otherwise notified by CMS.

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Annual Cost to Federal Government: $270,187

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 01/11/2008

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