Monthly State File of Medicaid/Medicare Dual Eligible Enrollees

Monthly State File of Medicaid/Medicare Dual Eligible Enrollees (CMS-10143)

⚠️ Notice: This information collection may be referencing outdated material.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
MAPD State User Guide 2018 PRA.pdf www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/MAPD-State-User-Guide-Version Instruction
MMA File Crosswalk PRA 04 12 2018.xlsx Crosswalk IC Document

Information Collection (IC) Details

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			MAPD State User Guide 2018 PRA.pdf	www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/mapdhelpdesk/Downloads/MAPD-State-User-Guide-Version-60.pdf	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	612	0	612
Annual IC Time Burden (Hours)	4,896	-1,224	6,120
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	MMA File Crosswalk PRA 04 12 2018.xlsx	08/27/2018

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