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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.