Applicable Integrated Plan Coverage Decision Letter (CMS-10716)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS10716Responseto30DayComments.pdf	Supplementary Document	Uploaded 2020-08-19	Available
CMS10716Crosswalk30dayToFinal.pdf	Supplementary Document	Uploaded 2020-08-19	Available
CMS10716SupportingStatement Clean.docx	Supporting Statement A	Uploaded 2020-11-24	Available
CMS10716ResponsetoPublicComments03092020.pdf	Supplementary Document	Uploaded 2020-04-14	Available
CMS_10716Crosswalk60dayTo30day03232020.pdf	Supplementary Document	Uploaded 2020-04-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
241332	Applicable Integrated Plan Coverage Decision Letter	Instruction	New

ICR Details

OMB Control No: 0938-1386	ICR Reference No: 202004-0938-003
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Applicable Integrated Plan Coverage Decision Letter (CMS-10716)
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: 11/27/2020
	Date Received in OIRA: 04/15/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2023	36 Months From Approved
Responses	693	0	0
Time Burden (Hours)	116	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This information collection request is for the “Applicable Integrated Plan Coverage Decision Letter” or the “coverage decision letter” will be issued as a result of an integrated organization determination under 42 CFR 422.631, when an applicable integrated plan reduces, stops, suspends, or denies, in whole or in part, a request for a service/item (including a Part B drug) or a request for payment of a service/item (including a Part B drug) the member has already received. “Applicable integrated plans” are defined at 42 CFR 422.561 as full integrated dual special needs plans (FIDE SNPs) and highly integrated dual special needs plans (HIDE SNPs) with exclusively aligned enrollment, where state policy limits the D-SNP’s membership to a Medicaid managed care plan offered by the same organization. These plans will issue the coverage decision letter starting in CY 2021 in place of the Notice of Denial of Medical Coverage (or Payment) (NDMCP) form (CMS-10003) as part of requirements to unify appeals and grievance processes.

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Authorizing Statute(s): PL: Pub.L. 115 - 123 50311(b) Name of Law: Bipartisan Budget Act of 2018
   US Code: 42 USC 1395w–28 Name of Law: null
  

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:
	84 FR 55966	10/18/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 21009	04/15/2020
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
Applicable Integrated Plan Coverage Decision Letter	CMS-10716, CMS-10716	Integrated Coverage Decision Letter ,   Integrated Coverage Decision Letter (Spanish)

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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	693	0	0	0	693	0
Annual Time Burden (Hours)	116	0	0	0	116	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:

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Annual Cost to Federal Government: $0

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]? 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? No

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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: 04/15/2020

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