Medicaid Program; Medicare Savings Program Application and Eligibility Determinations (CMS-10891)

Forms and Documents

Document Name	Status
final comment response 9-26-2024.docx Supplementary Document	2024-11-29
CMS-10891 - Supporting Statement A (2024 version 11).docx Supporting Statement A	2024-11-29

IC Document Collections

IC ID	Document Title	Status
272707	Burden on Individuals and States Other-Medicare Advantage Multi-Language Insert (MLI)	New

ICR Details

OMB Control No:	ICR Reference No: 202411-0938-013
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: FCHCO
Title: Medicaid Program; Medicare Savings Program Application and Eligibility Determinations (CMS-10891)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/29/2024

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	3,460,750	0
Time Burden (Hours)	5,517,157	0
Cost Burden (Dollars)	0	0

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Abstract: States use information collected by SSA on LIS applications, transmitted to states with the consent of an individual completing an application, to determine eligibility for the MSPs. The state Medicaid agency accepts and verifies the information provided on the LIS application (to the extent allowable under the MSP final rule); communicates with the applicant or the authorized representative about any additional information needed to make an MSP determination; makes the MSP eligibility determination; enrolls the individual in an MSP, if eligible; and informs the individual about the rights and responsibilities for applying for full Medicaid eligibility. Applicants include anyone who chooses to apply for LIS and provides consent for their application to be considered for MSPs. Information collected by state Medicaid agencies on an MSP-only application will be used to determine eligibility for MSPs. Applicants are anyone who wants to apply for MSPs. Information collected by the CMS model application for MSPs can be used to determine eligibility for MSPs if a state accepts the model application form. Applicants are anyone who wants to apply for MSPs and lives in a state that accepts the model application. Life insurance information collected by state Medicaid agencies such as the name of the insurance company and policy number is used to help individuals obtain the cash surrender value of life insurance policies in order to determine eligibility for MSPs. Affected individuals are those who apply for MSPs and need to provide documentation for states to evaluate whole life insurance policies. Individuals may refuse to provide consent. The information collection requirements will assist the public to understand information about the MSPs and will assist CMS in ensuring a simplified system of MSP application, eligibility determination, and enrollment.

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Authorizing Statute(s): EO: EO 13985 Name/Subject of EO: Advancing Racial Equity and Support for Underserved Communities Through the Federal Government
   EO: EO 14099 Name/Subject of EO: Strengthening Medicaid and the Affordable Care Act
   EO: EO 14070 Name/Subject of EO: Continuing To Strengthen Americans' Access to Affordable, Quality Health Coverage
   EO: EO 14058 Name/Subject of EO: Transforming Federal Customer Experience and Service Delivery To Rebuild Trust in Government
   PL: Pub.L. 110 - 275 113 and 118 Name of Law: Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 27764	04/18/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 93607	11/27/2024
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Burden on Individuals and States	CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891, CMS-10891	Application for Medicare Savings Programs (MSP) (English) ,   Application for Medicare Savings Programs (MSP) (Hindi) ,   Application for Medicare Savings Programs (MSP) (Arabic) ,   Application for Medicare Savings Programs (MSP) (French Creole) ,   Application for Medicare Savings Programs (MSP) (French) ,   Application for Medicare Savings Programs (MSP) (German) ,   Application for Medicare Savings Programs (MSP) (Italian) ,   Application for Medicare Savings Programs (MSP) (Japanese) ,   Application for Medicare Savings Programs (MSP) (Korean) ,   Application for Medicare Savings Programs (MSP) (Polish) ,   Application for Medicare Savings Programs (MSP) (Portuguese) ,   Application for Medicare Savings Programs (MSP) (Russian) ,   Application for Medicare Savings Programs (MSP) (Simplified Chinese) ,   Application for Medicare Savings Programs (MSP) (Spanish) ,   Application for Medicare Savings Programs (MSP) (Tagalog) ,   Application for Medicare Savings Programs (MSP) (Traditional Chinese) ,   Application for Medicare Savings Programs (MSP) (Vietnamese)

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ICR Summary of Burden

	Total Request	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	3,460,750	0	0	3,460,750	0	0
Annual Time Burden (Hours)	5,517,157	0	0	5,517,157	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Overall (see Table 4 of the Supporting Statement), we estimate a burden of 5,517,157 hours at a cost of $80,267,994. Other than the model MSP application, CMS does not have available any collection/reporting instruments regarding these collections. Each state maintains their own instruments for collections and reporting information from applicants and beneficiaries. For the model MSP application, per MIPPA requirements, CMS needs to translate it into the top 10 languages other than English spoken by Medicare applicants. Based on comments received, CMS has translated the model MSP application into the following 16 languages: Arabic, French, German, Haitian Creole, Hindi, Italian, Japanese, Korean, Polish, Portuguese, Russian, Simplified Chinese, Spanish, Tagalog, Traditional Chinese and Vietnamese. CMS chose these languages based on the languages used in the Medicare Advantage multi-language insert (MLI) and reflect the top 15 non-English languages used in the United States. We have revised the model MSP application based on public comments received and our internal review. We discuss all of those changes in a separate response to comments document.

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Annual Cost to Federal Government: $80,664,254

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.     Yes

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]? Yes

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: 11/29/2024

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