Dual Eligible Special Needs Plan Contract with the State Medicaid Agency

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

OMB: 0938-1410

IC ID: 251117

Information Collection (IC) Details

View Information Collection (IC)

Dual Eligible Special Needs Plan Contract with the State Medicaid Agency
 
No Modified
 
Mandatory
 
42 CFR 422.107(d) 42 CFR 422.107(e) 42 CFR 422.107 42 CFR 422.107(c)(9) 42 CFR 422.561

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(ies) Contract(s): Attestations Appendix A - Attestations.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10796 Appendix B - D-SNP State Medicaid Agency Contract Matrix.docx Appendix B - D-SNP State Medicaid Agency Contract Matrix.docx Yes Yes Fillable Fileable
Form and Instruction CMS-10796 Appendix C - Special Needs Plan (SNP) Contract Status Review Matrix Appendix C - Special Needs Plan (SNP) Contract Status Review Matrix.docx Yes Yes Fillable Fileable

Health Health Care Services

 

512 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 525 0 525 0 0 0
Annual IC Time Burden (Hours) 22,432 0 22,432 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

© 2024 OMB.report | Privacy Policy