Information Collection

Test of the MCBS Pulse Supplement: Beneficiary Trust

IC 277465 under ICR 202404-0938-005 · OMB 0938-1275.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10549 Test of the MCBS Pulse Supplement: Beneficiary Trust	Form and Instruction
CMS-10549 Test Questionnaire Attachment F. MCBS Rapid Cycle Specs.pdf	Form and Instruction
Supporting Statement_MCBS Beneficiary Trust Supplement_.docx Supporting Statement	IC Document
Attachment A. Community Advance Letter.docx Community Advance Letter	IC Document
Attachment B. Contacting Guide.docx Contacting Guide	IC Document
Attachment C. Reminder Postcard.docx Reminder Postcard	IC Document
Attachment D. Frequently Asked Questions_2021 Panel.docx Frequently Asked Questions_2021 Panel	IC Document
Attachment E. Frequently Asked Questions_2022-2024 Panels.docx Frequently Asked Questions_2022-2024 Panels	IC Document

IC Title:

Agency IC Tracking Number:

OEDA

IC Status: New

Obligation to Respond: Voluntary

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
Form and Instruction	CMS-10549	Test Questionnaire	Attachment F. MCBS Rapid Cycle Specs.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	5,800	5,800
Annual IC Time Burden (Hours)	1,624	1,624
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	Supporting Statement_MCBS Beneficiary Trust Supplement_.docx	09/15/2025
Community Advance Letter	Attachment A. Community Advance Letter.docx	09/15/2025
Contacting Guide	Attachment B. Contacting Guide.docx	09/15/2025
Reminder Postcard	Attachment C. Reminder Postcard.docx	09/15/2025
Frequently Asked Questions_2021 Panel	Attachment D. Frequently Asked Questions_2021 Panel.docx	09/15/2025
Frequently Asked Questions_2022-2024 Panels	Attachment E. Frequently Asked Questions_2022-2024 Panels.docx	09/15/2025

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