Initial and Renewal Model of Care Submissions, and Off-cycle Submission of Summaries of Model of Care Changes (CMS-10565)

Forms and Documents

Document Name	Status
Form CMS-10565 Off-cycle Submission of Summaries (MOC Changes) Form	New
Form CMS-10565 Initial and renewal MOC Submissions Form	New
CMS-10565 -Supporting Statement A [rev 12-31-2015 at 0655 am by OSORA PRA] - CLEAN.docx Supporting Statement A	2015-12-31

IC Document Collections

IC ID	Document Title	Status
218542	Off-cycle Submission of Summaries (MOC Changes) Form	New
218541	Initial and renewal MOC Submissions Form	New

ICR Details

OMB Control No: 0938-1296	ICR Reference No: 201510-0938-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Initial and Renewal Model of Care Submissions, and Off-cycle Submission of Summaries of Model of Care Changes (CMS-10565)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/31/2015
	Date Received in OIRA: 10/09/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2018	36 Months From Approved
Responses	376	0	0
Time Burden (Hours)	2,130	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Medicare Advantage (MA) Special Needs Plans (SNPs) are required to submit Models of Care (MOCs) as a component of the MA application process. The Affordable Care Act (ACA) requires that all SNPs be approved by the National Committee for Quality Assurance (NCQA). This approval is based on NCQA’s evaluation of SNPs using MOC scoring guidelines developed by CMS and NCQA for the Secretary of the Department of Health and Human Services (DHHS). The MOC elements cover the following areas: MOC 1- Description of the SNP Population; MOC 2 - Care Coordination; MOC 3 - Provider Network; and MOC 4 - Quality Measurement & Performance Improvement. SNPs submit a MOC at time of their initial application and based on their scores, SNPs receive an approval for a period of 1, 2 or 3 years. After the approval period expires, SNPs are required to submit an updated MOC for review for their renewal process. CMS is also developing a MOC off-cycle revision process so that SNPs can revise the MOC to modify its processes and strategies for providing care during their MOC approval period. CMS will require that SNPs submit summaries of their MOC revisions to CMS for NCQA evaluation when a SNP makes significant changes to its MOC during the approval period. NCQA will review the summary of changes to verify that the revisions are consistent with the acceptable, high quality standards as included in the original approved MOC. CMS will begin collecting MOCs mid-January 2016 to coincide with the MA Application collection.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 3205(e) Name of Law: The Patient Protection and Affordable Care Act (ACA)
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3205(e) Name of Law: The Patient Protection and Affordable Care Act (ACA)

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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:
	80 FR 34647	06/17/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 60150	10/05/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Initial and renewal MOC Submissions	CMS-10565	Model of Care Matrix Upload Document for Initial Application and Renewal
Off-cycle Submission of Summaries (MOC Changes)	CMS-10565	Revised Model of Care Matrix Upload Document

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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	376	0	376	0	0	0
Annual Time Burden (Hours)	2,130	0	2,130	0	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: No

Burden Reduction Due to:

Short Statement: No changes. This is a new collection.

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Annual Cost to Federal Government: $427,921

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]? Yes

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: 10/09/2015

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