Disclosure of Eligibility Criteria for Supplemental Benefits for the Chronically Ill (SSBCI) (CMS-10915)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-10915 - Supporting Statement A (CMS-4208-P version 4).docx	Supporting Statement A	Uploaded 2025-01-17	Repair queued
CMS-10915 - Supporting Statement A (CMS-4208-P version 4).docx	Supporting Statement A	Uploaded 2025-01-17	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
273765	Disclosure of Eligibility Criteria for Supplemental Benefits for the Chronically Ill (SSBCI)		New

ICR Details

OMB Control No:	ICR Reference No: 202501-0938-009
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Disclosure of Eligibility Criteria for Supplemental Benefits for the Chronically Ill (SSBCI) (CMS-10915)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 02/19/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/17/2025
Terms of Clearance: Withdrawing at the request of the agency.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: In accordance with 42 CFR 102(f)(4) each MA organization under Part C Medicare is required to “list all the written policies and objective criteria on which the policies are based as noted in paragraph (f)(4)(i) of this section on their public facing website.”

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Authorizing Statute(s): US Code: 42 USC 422.102(f)(4)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV40	Proposed rulemaking	89 FR 99340	12/10/2024

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 99340	12/10/2024
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Disclosure of Eligibility Criteria for Supplemental Benefits for the Chronically Ill (SSBCI)

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

Burden Increase Due to: Changing Regulations

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

Burden Reduction Due to:

Short Statement: This iteration is associated with our December 10, 2024 (89 FR 99340) proposed rule (CMS-4208-P, RIN 0938-AV40). At 42 CFR 422.102(f)(4)(iii)(C) plans must “For each SSBCI, the MA plan must list all the written policies and objective criteria on which the policies are based as noted in paragraph (f)(4)(i) of this section on their public facing website.” This new requirement will allow enrollees to review and determine whether they may be eligible for SSBCI. Plans may heavily market certain SSBCI and this new requirement provides enrollees the ability to ensure they are eligible for SSBCI which may improve or maintain the health or function of the enrollee. Since plans are also required to “Maintain without modification, as it relates to an SSBCI, evidentiary standards for a specific enrollee to be determined eligible for a particular SSBCI, or the specific objective criteria used by a plan as part of SSBCI eligibility determinations for the full coverage year” as set forth in 42 CFR 422.102(f)(4)(v), this also ensures a level of assurance to enrollees and CMS that plans are consistent how they offer SSBCI and determine eligibility. This information will be useful to CMS in performing audits and compliance reviews regarding SSBCI eligibility determinations. The rule would add an annual burden of 1,522 hours and $190,981 for 791 plans. There are no collection of information instruments or instruction beyond what is published in the proposed rule.

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Annual Cost to Federal Government: $10,306

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.     No

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]? No

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: 01/17/2025

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