Applicable Integrated Plan Coverage Decision Letter

Applicable Integrated Plan Coverage Decision Letter (CMS-10716)

OMB: 0938-1386

IC ID: 241332

Documents and Forms
Document Name
Document Type
Instruction
Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

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Applicable Integrated Plan Coverage Decision Letter
 
No Modified
 
Mandatory
 
42 CFR 422.631 42 CFR 422.561

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction CMS10716FormInstructions Updated April 2024.docx Yes No Fillable Printable
Form and Instruction CMS-10716 Integrated Coverage Decision Letter DSNPCoverageDecisionLetterIntegrated Updated April 2024.docx Yes Yes Fillable Printable
Form and Instruction CMS-10716 Integrated Coverage Decision Letter (Spanish) DSNPCoverageDecisionLetter_2023_Spanish.pdf Yes Yes Fillable Printable

Health Health Care Services

 

112 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 24,716 0 0 0 0 24,716
Annual IC Time Burden (Hours) 4,120 0 0 0 0 4,120
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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