Information Collection

Applicable Integrated Plan Coverage Decision Letter

IC 241332 under ICR 202404-0938-023 · OMB 0938-1386.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1386 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS10716FormInstructions Updated April 2024.docx	Instruction
CMS10716FormInstructions Updated April 2024.docx	Instruction
CMS-10716 Integrated Coverage Decision Letter DSNPCoverageDecisionLetterIntegrated Updated April 2024.docx	Form and Instruction
CMS-10716 Integrated Coverage Decision Letter DSNPCoverageDecisionLetterIntegrated Updated April 2024.docx	Form and Instruction
CMS-10716 Integrated Coverage Decision Letter (Spanish) DSNPCoverageDecisionLetter_2023_Spanish.pdf	Form and Instruction
CMS-10716 Integrated Coverage Decision Letter (Spanish) DSNPCoverageDecisionLetter_2023_Spanish.pdf	Form and Instruction

IC Title:

Applicable Integrated Plan Coverage Decision Letter

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.631 42 CFR 422.561

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 112

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	24,716	24,716
Annual IC Time Burden (Hours)	4,120	4,120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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