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	Unchanged
Form CMS-10565 Initial and renewal MOC Submissions Form	Unchanged
PRA CMS-10565 -MOC Supporting Statement 30 day V2.docx Supporting Statement A	2019-05-31
Final Appendix A-CMS 10565 Response to Comments 30 day.doc Supplementary Document	2019-05-14
PRA CMS -10565 MOC Crosswalk.pdf Supplementary Document	2019-04-01
CMS 10565 Appendix A Response to Public Comments.doc Supplementary Document	2019-03-26

IC Document Collections

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

ICR Details

OMB Control No: 0938-1296	ICR Reference No: 201905-0938-021
Status: Active	Previous ICR Reference No: 201903-0938-014
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: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/03/2019
	Date Received in OIRA: 05/31/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2022	36 Months From Approved
Responses	323	0	0
Time Burden (Hours)	1,732	0	0
Cost Burden (Dollars)	0	0	0

---

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.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 3205(e) Name of Law: The Patient Protection and Affordable Care Act (ACA)
   PL: Pub.L. 111 - 148 1859 (b)(6)(B)(iii) Name of Law: The Bipartisan Budget Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3205(e) Name of Law: The Patient Protection and Affordable Care Act (ACA)
PL: Pub.L. 111 - 148 1859 (b)(6)(B)(iii) Name of Law: The Bipartisan Budget Act

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 55891	11/08/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 11799	03/28/2019
Did the Agency receive public comments on this ICR? No

---

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

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

---

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	323	0	0	-53	0	376
Annual Time Burden (Hours)	1,732	0	0	-398	0	2,130
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: Yes

Burden Reduction Due to: Changing Regulations

Short Statement: As a result of the BBA mandate for annual C-SNP MOC submissions and based on comments from SNPs and industry advocates to reduce burden on C-SNPs, CMS is eliminating the off-cycle MOC submission process for C-SNPs. There is a minimal increase in burden for C-SNPs because they are now required to submit a MOC annually.

---

Annual Cost to Federal Government: $680,955

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

---

Common Form ICR:  No

---

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: 05/31/2019

---