Information Collection

Monthly State File of Medicaid/Medicare Dual Eligible Enrollees

IC 8816 under ICR 202005-0938-016 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	612	612
Annual IC Time Burden (Hours)	4,896	4,896
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.