Information Collection

Dual Eligible Special Needs Plan Contract with the State Medicaid Agency

IC 251117 under ICR 202201-0938-009 · OMB 0938-1410.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1410 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10796 Dual Eligible Special Needs Plan Contract with the State Medicaid Agency Form and Instruction
CMS-10796 D-SNP State Medicaid Agency Contract Matrix Appendix A - D-SNP State Medicaid Agency Contract Matrix (CMS-4192-P version 2).pdf Form and Instruction
CMS-10796 D-SNP State Medicaid Agency Contract Matrix Appendix A - D-SNP State Medicaid Agency Contract Matrix (CMS-4192-P version 2).pdf Form and Instruction
CMS-10796 Special Needs Plan (SNP) Contract Status Review Matrix Appendix B - Special Needs Plan (SNP) Contract Status Review Matrix (CMS-4192-P version 2).pdf Form and Instruction
CMS-10796 Special Needs Plan (SNP) Contract Status Review Matrix Appendix B - Special Needs Plan (SNP) Contract Status Review Matrix (CMS-4192-P version 2).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Dual Eligible Special Needs Plan Contract with the State Medicaid Agency	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Form and Instruction	CMS-10796	D-SNP State Medicaid Agency Contract Matrix	Appendix A - D-SNP State Medicaid Agency Contract Matrix (CMS-4192-P version 2).pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10796	Special Needs Plan (SNP) Contract Status Review Matrix	Appendix B - Special Needs Plan (SNP) Contract Status Review Matrix (CMS-4192-P version 2).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 511	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	633	633
Annual IC Time Burden (Hours)	20,968	20,968
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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