Information Collection

Monthly State File of Medicaid/Medicare Dual Eligible Enrollees

IC 8816 under ICR 200807-0938-002 · OMB 0938-0958.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0958 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10143 Monthly State File of Medicaid/Medicare Dual Eligible Enrollees	Form and Instruction
CMS-10143 Medicare Modernization Act (MMA) State File Specificatio CMS-10143 instrument-data dictionary.doc	Form and Instruction

IC Title:

Monthly State File of Medicaid/Medicare Dual Eligible Enrollees

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10143	Medicare Modernization Act (MMA) State File Specifications and Data Dictionary	CMS-10143 instrument-data dictionary.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	612	0	612
Annual IC Time Burden (Hours)	6,120	-4,590	10,710
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.