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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10796 Appendix C - Special Needs Plan (SNP) Contract Status Review Matrix	Form and Instruction	Modified	Available
Form CMS-10796 Appendix B - D-SNP State Medicaid Agency Contract Matrix.docx	Form and Instruction	Modified	Available
Form CMS-10796 D-SNP State Medicaid Agency(ies) Contract(s): Attestations	Form and Instruction	Modified	Available
Form CMS-10796 Dual Eligible Special Needs Plan Contract with the State Medicaid Agency	Form and Instruction	Modified	Available
CMS-10796 - Supporting Statement A (CMS-4192-F).docx	Supporting Statement A	Uploaded 2022-06-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
251117	Dual Eligible Special Needs Plan Contract with the State Medicaid Agency	Form and Instruction	Modified	Appendix C - Special Needs Plan (SNP) Contract Status Review Matrix
251117	Dual Eligible Special Needs Plan Contract with the State Medicaid Agency	Form and Instruction	Modified	Appendix B - D-SNP State Medicaid Agency Contract Matrix.docx
251117	Dual Eligible Special Needs Plan Contract with the State Medicaid Agency	Form and Instruction	Modified	D-SNP State Medicaid Agency(ies) Contract(s): Attestations
251117	Dual Eligible Special Needs Plan Contract with the State Medicaid Agency	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1410	ICR Reference No: 202206-0938-002
Status: Historical Active	Previous ICR Reference No: 202201-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Dual Eligible Special Needs Plan Contract with the State Medicaid Agency (CMS-10796)
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 without change	Conclusion Date: 08/01/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/01/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2025	36 Months From Approved
Responses	525	0	0
Time Burden (Hours)	22,432	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): PL: Pub.L. 115 - 123 50311(b) Name of Law: Bipartisan Budget Act of 2018
   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
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AU30	Final or interim final rulemaking	87 FR 27704	05/09/2022

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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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
Dual Eligible Special Needs Plan Contract with the State Medicaid Agency	CMS-10796, CMS-10796, CMS-10796	D-SNP State Medicaid Agency(ies) Contract(s): Attestations ,   Appendix B - D-SNP State Medicaid Agency Contract Matrix.docx ,   Appendix C - Special Needs Plan (SNP) Contract Status Review Matrix

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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	525	0	0	525	0	0
Annual Time Burden (Hours)	22,432	0	0	22,432	0	0
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: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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Annual Cost to Federal Government: $169,821

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: 06/01/2022

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