Medicare Plan Performance Warning Information (CMS-10836)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10836 Poor Plan Performance - Intemediaries	Form and Instruction	New	Repair queued
Form CMS-10836 Poor Plan Performance - Beneficiaries	Form and Instruction	New	Available
Form CMS-10836 Enforcement and Compliance Information - Intermediaries	Form and Instruction	New	Repair queued
Form CMS-10836 Enforcement and Compliance Information - Beneficiaries	Form and Instruction	New	Repair queued
Form CMS-10836 Audits and Letters - Intermediaries	Form and Instruction	New	Repair queued
Form CMS-10836 Audits and Letters - Beneficiaries and Caregivers	Form and Instruction	New	Repair queued
Form CMS-10836 IDI Discussion Guide	Form and Instruction	New	Repair queued
Form CMS-10836 Interview Screener: Typical Beneficiaries: Caregivers	Form and Instruction	New	Repair queued
Form CMS-10836 Interview Screener: Typical and Engaged Beneficiaries	Form and Instruction	New	Repair queued
Form CMS-10836 Scheduling/Screening	Form and Instruction	New	Repair queued
CMS-10836 -Supporting Statement A -.docx	Supporting Statement A	Uploaded 2023-03-15	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
259113	IDI Discussion Guide	Form and Instruction	New	Poor Plan Performance - Intemediaries
259113	IDI Discussion Guide	Form and Instruction	New	Poor Plan Performance - Beneficiaries
259113	IDI Discussion Guide	Form and Instruction	New	Enforcement and Compliance Information - Intermediaries
259113	IDI Discussion Guide	Form and Instruction	New	Enforcement and Compliance Information - Beneficiaries
259113	IDI Discussion Guide	Form and Instruction	New	Audits and Letters - Intermediaries
259113	IDI Discussion Guide	Form and Instruction	New	Audits and Letters - Beneficiaries and Caregivers
259113	IDI Discussion Guide	Form and Instruction	New
259110	Scheduling/Screening	Form and Instruction	New	Interview Screener: Typical Beneficiaries: Caregivers
259110	Scheduling/Screening	Form and Instruction	New	Interview Screener: Typical and Engaged Beneficiaries
259110	Scheduling/Screening	Form and Instruction	New

ICR Details

OMB Control No: 0938-1456	ICR Reference No: 202303-0938-005
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Medicare Plan Performance Warning Information (CMS-10836)
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 with change	Conclusion Date: 12/18/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/15/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2026	36 Months From Approved
Responses	576	0	0
Time Burden (Hours)	561	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Centers for Medicare & Medicaid Services (CMS) is seeking approval to collect information to assist in the Agency’s response to two reports from the Department of Health and Human Services Office of the Inspector General (OIG) related to how the agency conveys information on plan performance. CMS is conducting this research to respond to OIG’s recommendations related to sharing clear and accessible information with beneficiaries on plan performance, particularly related to information which may warn or caution beneficiaries about plan performance issues. CMS is seeking to learn more about how beneficiaries, caregivers, and the intermediaries who assist them use and understand the information CMS currently makes (or may make) available, as well as to assess their interest in accessing this information.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 722(a)(3)(A)(i) Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 76626	12/15/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 15036	03/10/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
IDI Discussion Guide	CMS-10836, CMS-10836, CMS-10836, CMS-10836, CMS-10836, CMS-10836	Audits and Letters - Beneficiaries and Caregivers ,   Audits and Letters - Intermediaries ,   Enforcement and Compliance Information - Beneficiaries ,   Enforcement and Compliance Information - Intermediaries ,   Poor Plan Performance - Beneficiaries ,   Poor Plan Performance - Intemediaries
Scheduling/Screening	CMS-10836, CMS-10836	Interview Screener: Typical and Engaged Beneficiaries ,   Interview Screener: Typical Beneficiaries: Caregivers

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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	576	0	0	0	576	0
Annual Time Burden (Hours)	561	0	0	0	561	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $767,713

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: 03/15/2023

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