Medicare Advantage Application - Part C and 1876 Cost Plan Expansion Application regulations under 42 CFR 422 subpart K & 417.400

Forms and Documents

Document Name	Status
Form CMS-10237 Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012) Form and Instruction	Modified
2012 PRA CommentTracking (Response to 60 daynotice).xls Supplementary Document	2010-09-17
2012 High Level Sum- Changes from 60 Comment Period_V3_Rev_1.docx Supplementary Document	2010-09-17
CMS MA Signature Authority Grid (2012 Draft).xls Supplementary Document	2010-09-17
CMS MA Provider Table (2012 Draft).xls Supplementary Document	2010-09-17
CMS MA Facility Table (2012 Draft).xls Supplementary Document	2010-09-17
2012 Draft HSD Instructions Clean (PRA-30daynotice).doc Supplementary Document	2010-09-17
CMS MA Contract and Signature Index-Facilities (2012 Draft).xls Supplementary Document	2010-09-17
CMS MA Additional and Supplment Benefits Table (2012 Draft).xls Supplementary Document	2010-09-17
Supporting Statement for 2012 Applications(30 daycomment).doc Supporting Statement A	2010-09-17

IC Document Collections

IC ID	Document Title	Status
8785	Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0935	ICR Reference No: 201009-0938-017
Status: Historical Active	Previous ICR Reference No: 200910-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Advantage Application - Part C and 1876 Cost Plan Expansion Application regulations under 42 CFR 422 subpart K & 417.400
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: 12/20/2010
	Date Received in OIRA: 09/30/2010
Terms of Clearance: Consistent with the PRA, this ICR should be re-submitted along with the publication of any draft "forthcoming guidance" documents to the extent that such guidance documents would result in new information collection, recordkeeping, or disclosure requirements or result in changes to burden or capital cost from existing requirements.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2011	36 Months From Approved	01/31/2011
Responses	870	0	291
Time Burden (Hours)	15,696	0	9,547
Cost Burden (Dollars)	0	0	0

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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.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 1857 Name of Law: Medicare Advantage
   PL: Pub.L. 110 - 275 161 Name of Law: Provisions relating to Part C
   US Code: 42 USC 1395mm Name of Law: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AP77	Final or interim final rulemaking	75 FR 19803	04/15/2010

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 33308	06/11/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 57035	09/17/2010
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)	CMS-10237	Medicare Advantage Application - Part C and 1876 Cost Plan Expansion Application

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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	870	291	0	579	0	0
Annual Time Burden (Hours)	15,696	9,547	0	6,149	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: Increase in respondents: For contract year 2012, CMS expects a slight increase in initial applicants and SAE applications based on CY 2011 application submissions, and a major increase in the number SNP proposal submissions. Increase Burden of Hours: An additional 2 hours of burden was added to the base MA application. This increase stems from changes in regulations at 42 CFR 422 with regards to the compliance plans and quality improvement plans. CMS made an internal decision to have organizations' submit its compliance plan and quality improvement program plans as a part of the application process. CMS believes having this information will help us evaluation an organization understanding of the MA programs and the organization's readiness to serve beneficiaries as a MA contractor. CMS has also made an internal decision to have MA contractors that are currently offering a SNP product to complete and submit a modified SNP proposal. CMS believes having this information will help us better evaluate the quality of health care being offered across all SNP programs.

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Annual Cost to Federal Government: $2,877,000

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

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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: 09/30/2010

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