Information Collection

Monthly State File of Medicaid/Medicare Dual Eligible Enrollees

IC 8816 under ICR 201511-0938-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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
MMA Data Dictionary 20150519f.docx Instruction
MMAPRA CrosswalkF.docx Crosswalk IC Document

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
Instruction			MMA Data Dictionary 20150519f.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Beneficiary Database (MBD)	FR Citation: 80 FR 49237

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	Previously Approved
Annual Number of Responses for this IC	612	612
Annual IC Time Burden (Hours)	6,120	6,120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	MMAPRA CrosswalkF.docx	11/19/2015

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