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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10237 CMS-10237 Part C MA and Cost Plan Applications	Form and Instruction	Modified	Available
Form CMS-10237 CMS-10237_MA_Provider_Table_2013.	Form	Modified	Available
Form CMS-10237 CMS-10237_MA_Facility_Table_2013	Form	Modified	Available
Form CMS-10237 2013_HSD_Exception_Request_Template	Form and Instruction	Modified	Available
CMS-10237.2013 High Levels Summary of Changes (for final clearance).docx	Supplementary Document	Uploaded 2012-01-09	Available
Copy of CMS-10237.Part C response to 30 day comments.12-13-11.xlsx	Supplementary Document	Uploaded 2012-01-09	Available
2013_High_Levels_Summary_of_Changes_(REVISED).pdf	Supplementary Document	Uploaded 2011-11-02	Available
2013_High_Levels_Summary_of_Changes_(REVISED).pdf	Supplementary Document	Uploaded 2011-11-02	Available
CMS-10237_Supporting_Statement_for_2013_Applications.pdf	Supporting Statement A	Uploaded 2011-11-02	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8785	Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)	Form and Instruction	Modified	CMS-10237 Part C MA and Cost Plan Applications
8785	Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)	Form	Modified	CMS-10237_MA_Provider_Table_2013.
8785	Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)	Form	Modified	CMS-10237_MA_Facility_Table_2013
8785	Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)	Instruction	Modified
8785	Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)	Form and Instruction	Modified	2013_HSD_Exception_Request_Template

ICR Details

OMB Control No: 0938-0935	ICR Reference No: 201111-0938-003
Status: Historical Active	Previous ICR Reference No: 201009-0938-017
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 with change	Conclusion Date: 01/09/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/07/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2015	36 Months From Approved	01/31/2012
Responses	378	0	870
Time Burden (Hours)	13,296	0	15,696
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
  

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:
	76 FR 62414	10/07/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 38655	07/01/2011
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
Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)	CMS-10237, CMS-10237, CMS-10237, CMS-10237	2013_HSD_Exception_Request_Template ,   CMS-10237_MA_Facility_Table_2013 ,   CMS-10237_MA_Provider_Table_2013. ,   CMS-10237 Part C MA and Cost Plan Applications

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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	378	870	0	-492	0	0
Annual Time Burden (Hours)	13,296	15,696	0	-2,400	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Overall Decrease Burden of Hours: The decrease in the overall burden hours is due to the decrease in the expected number of respondents. The number of SNP-only request will decrease because CMS has made an internal decision to not have all MA contractors that are currently offering a SNP product to complete and submit a SNP proposal. Only the MA organizations currently offering a SNP that requires re-approval under the NCQA SNP Approval process would be required to submit the Model of Care written narrative and Model of Care Matrix Upload Document portion of the SNP Proposal. Increase Burden Hours per application: An additional 5 hours of burden was added to the Initial application. This increase stems from an internal assessment of the application materials. For CY2013, CMS added three (3) new templates to clarify information that is being requested and to reduce confusion amongst applicants and reviewers. CMS also added three (3) new attestations. These attestations stems from regulatory changes at 42 CFR 422 subpart K.

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Annual Cost to Federal Government: $948,400

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: 11/07/2011

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