Triennial Network Adequacy Review for Medicare Advantage Organizations and 1876 Cost Plans (CMS-10636)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10636 Partial County Justification Template	Form and Instruction	Modified	Available
Form CMS-10636 Exception Request Template	Form	Modified	Available
Form CMS-10636 Facility HSD Table	Form	Modified	Available
Form CMS-10636 Provider HSD Table	Form	Modified	Available
CMS-10636 - Supporting Statement A (CMS-4201-P version 3).docx	Supporting Statement A	Uploaded 2023-03-15	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
227912	Three-Year Network Adequacy Review for Medicare Advantage Organizations	Form and Instruction	Modified	Partial County Justification Template
227912	Three-Year Network Adequacy Review for Medicare Advantage Organizations	Form	Modified	Exception Request Template
227912	Three-Year Network Adequacy Review for Medicare Advantage Organizations	Form	Modified	Facility HSD Table
227912	Three-Year Network Adequacy Review for Medicare Advantage Organizations	Form	Modified	Provider HSD Table
227912	Three-Year Network Adequacy Review for Medicare Advantage Organizations	Instruction	Modified

ICR Details

OMB Control No: 0938-1346	ICR Reference No: 202303-0938-009
Status: Historical Inactive	Previous ICR Reference No: 202208-0938-018
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Triennial Network Adequacy Review for Medicare Advantage Organizations and 1876 Cost Plans (CMS-10636)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 04/26/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/15/2023
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2024	36 Months From Approved	11/30/2024
Responses	2,753	0	2,753
Time Burden (Hours)	27,470	0	27,470
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information request is authorized under Section 1852(d)(1) of the Social Security Act which permits an MA organization to select the providers from which an enrollee may receive covered benefits, provided that the MA organization makes such benefits available and accessible in the service area with promptness and in a manner which assures continuity in the provision of benefits as defined in §§422.112(a)(1)(i) and 422.114(a)(3)(ii) (under Part 422, Subpart C – benefits and beneficiary protections) and §§417.414(b) and 417.416(a) and (e) (under Part 417, Subpart J – Qualifying Conditions for Medicare Contracts).

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Authorizing Statute(s): US Code: 42 USC 1852 Name of Law: Health Insurance for the Aged and Disabled: Benefits and Beneficiary Protections
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AU96	Proposed rulemaking	87 FR 79452	12/27/2022

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 79452	12/27/2022
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
Three-Year Network Adequacy Review for Medicare Advantage Organizations	CMS-10636, CMS-10636, CMS-10636, CMS-10636	Provider HSD Table ,   Facility HSD Table ,   Exception Request Template ,   Partial County Justification Template

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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: $1,164,840

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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