Dual Eligible Special Needs Plan Contract with the State Medicaid Agency (CMS-10796)

ICR 202201-0938-009


Federal Form Document

ICR Details
Received in OIRA
Dual Eligible Special Needs Plan Contract with the State Medicaid Agency (CMS-10796)
New collection (Request for a new OMB Control Number)   No
Regular 01/13/2022
  Requested Previously Approved
36 Months From Approved
633 0
20,968 0
0 0

Medicare Advantage (MA) organizations with D-SNPs and States use the information in the contract to provide benefits, or arrange for the provision of Medicaid benefits, to which an enrollee is entitled. CMS reviews the D-SNP contract with the State Medicaid agency to ensure that it meets the requirements at § 422.107.

PL: Pub.L. 108 - 173 1859(b)(6) and 1859(f)(3)(D) Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003
   PL: Pub.L. 115 - 123 50311(b) Name of Law: Bipartisan Budget Act of 2018

0938-AU30 Proposed rulemaking 87 FR 1842 01/12/2022

  87 FR 1842 01/12/2022

  Total Request 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 633 0 0 633 0 0
Annual Time Burden (Hours) 20,968 0 0 20,968 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Changing Regulations
Our Contract Year 2023 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs rule (January 12, 2022; 87 FR 1842) (CMS-4192-P, RIN 0938-AU30) proposes to revise regulations related to the dual eligible special needs plan (D-SNP) contract with the State Medicaid agency. The burden for the creation and submission of the D-SNP contract with the State Medicaid agency is currently approved by OMB under control numbers 0938-0753 (CMS-R-267) and 0938-0935 (CMS-10237) and is being extracted into this new package (CMS-10796; OMB 0938-TBD). We are also proposing changes to our currently approved burden estimates to account for the proposed rule’s changes. Overall, we estimate a burden of 633 responses and 20,968 hours.

Mitch Bryman 410 786-5258 [email protected]


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:
    (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;
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.

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