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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.