Information Collection

Dual Eligible Special Needs Plan Contract with the State Medicaid Agency

IC 251117 under ICR 202206-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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(ies) Contract(s): Attestatio Appendix A - Attestations.docx Form and Instruction
CMS-10796 D-SNP State Medicaid Agency(ies) Contract(s): Attestatio Appendix A - Attestations.docx Form and Instruction
CMS-10796 Appendix B - D-SNP State Medicaid Agency Contract Matrix Appendix B - D-SNP State Medicaid Agency Contract Matrix.docx Form and Instruction
CMS-10796 Appendix B - D-SNP State Medicaid Agency Contract Matrix Appendix B - D-SNP State Medicaid Agency Contract Matrix.docx Form and Instruction
CMS-10796 Appendix C - Special Needs Plan (SNP) Contract Status Re Appendix C - Special Needs Plan (SNP) Contract Status Review Matrix.docx Form and Instruction
CMS-10796 Appendix C - Special Needs Plan (SNP) Contract Status Re Appendix C - Special Needs Plan (SNP) Contract Status Review Matrix.docx 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: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.107(d) 42 CFR 422.107(e) 42 CFR 422.107 42 CFR 422.107(c)(9) 42 CFR 422.561

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 512	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	525	525
Annual IC Time Burden (Hours)	22,432	22,432
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.