Information Collection

Monthly State File of Medicaid/Medicare Dual Eligible Enrollees

IC 8816 under ICR 202310-0938-008 · OMB 0938-0958.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
MAPD SUG 2018 to 2023 clean copy.docx www.cms.gov/files/document/mapd-state-user-guide-february-6-2023-version-110.pdf	Instruction
MAPD SUG 2018 to 2023 clean copy.docx www.cms.gov/files/document/mapd-state-user-guide-february-6-2023-version-110.pdf	Instruction
MAPD SUG 2018 to 2023 tracked changes.docx Track Change: User Guide	IC Document
MAPD SUG 2018 to 2023 tracked changes.docx Track Change: User Guide	IC Document
MAPD SUG Crosswalk 2018 TO 2023.xlsx Crosswalk: User Guide	IC Document
MAPD SUG Crosswalk 2018 TO 2023.xlsx Crosswalk: User Guide	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			MAPD SUG 2018 to 2023 clean copy.docx	https://www.cms.gov/files/document/mapd-state-user-guide-february-6-2023-version-110.pdf	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Beneficiary Database (MBD)

FR Citation: 80 FR 49237

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	612	612
Annual IC Time Burden (Hours)	4,896	4,896
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change: User Guide	MAPD SUG 2018 to 2023 tracked changes.docx	01/02/2024
Crosswalk: User Guide	MAPD SUG Crosswalk 2018 TO 2023.xlsx	10/30/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.