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 LOI Group to NPI Matrix Template	Form	Modified	Available
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-F_version 6).docx	Supporting Statement A	Uploaded 2023-09-22	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	Modified	LOI Group to NPI Matrix Template
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: 202305-0938-004
Status: Historical Active	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: Approved without change	Conclusion Date: 12/13/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/25/2023
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	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 proposed collection of information is essential to appropriate and timely compliance monitoring by CMS, in order to ensure that all active MAO contracts offering network-based plans maintain an adequate network. Currently, CMS verifies that MAOs are compliant with the current CMS network adequacy criteria by performing a contract-level network review, which occurs when CMS requests that an MAO upload provider and facility Health Service Delivery (HSD) tables for a given contract to the Health Plan Management System (HPMS). If an MAO does not have its contract-level network formally reviewed by CMS after the initial contract application process, then there is no CMS requirement for a network adequacy review unless one of the above listed triggering events occurs. Therefore, CMS is proposing this collection of information in order to improve monitoring of MAOs’ network adequacy. This collection of information requires the uploading of HSD tables to the Network Management Module (NMM) in HPMS for any contract that has not had an entire network review performed by CMS in the previous three years of contract operation. The collection process will occur at the contract level for each MAO that qualifies, and CMS will assess each contract against the current CMS network adequacy criteria. Each time an MAO’s contract undergoes an entire network review during any of the triggering events listed on page one, the three-year anniversary date for that contract will be reset, and CMS will maintain an HPMS report to keep track of this date for every active network-based contract.

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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	Final or interim final rulemaking	88 FR 22120	04/12/2023

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 79452	12/27/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 22120	04/12/2023
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, CMS-10636	Provider HSD Table ,   Facility HSD Table ,   Exception Request Template ,   Partial County Justification Template ,   LOI Group to NPI Matrix Template

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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	2,753	2,753	0	0	0	0
Annual Time Burden (Hours)	27,470	27,470	0	0	0	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: $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: 09/25/2023

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