Information Collection

Dual Eligible Special Needs Plan Contract with the State Medicaid Agency

IC 251117 under ICR 202503-0938-002 · OMB 0938-1410.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10796 Dual Eligible Special Needs Plan Contract with the State Medicaid Agency	Form and Instruction
Form CMS-10796 D-SNP State Medicaid Agency(ies) Contract(s): Attestations Dual Eligible Special Needs Plan Contract with the State Medicaid Agency	Form and Instruction
Form CMS-10796 Appendix B - D-SNP State Medicaid Agency Contract Matrix.docx Dual Eligible Special Needs Plan Contract with the State Medicaid Agency	Form and Instruction
Form CMS-10796 Appendix C - HIDE, FIDE, and AIP Contract Requirements Matrix Dual Eligible Special Needs Plan Contract with the State Medicaid Agency	Form and Instruction
CMS-10796 D-SNP State Medicaid Agency(ies) Contract(s): Attestatio Appendix A - Attestations.docx	Form and Instruction
CMS-10796 D-SNP State Medicaid Agency(ies) Contract(s): Attestatio Appendix A - Attestations.docx	Form and Instruction
CMS-10796 Appendix B - D-SNP State Medicaid Agency Contract Matrix Appendix B - Basic D-SNP SMAC Requirements Matrix.docx	Form and Instruction
CMS-10796 Appendix B - D-SNP State Medicaid Agency Contract Matrix Appendix B - Basic D-SNP SMAC Requirements Matrix.docx	Form and Instruction
CMS-10796 Appendix C - HIDE, FIDE, and AIP Contract Requirements M Appendix C - HIDE, FIDE, and AIP Contract Requirements Matrix.docx	Form and Instruction
CMS-10796 Appendix C - HIDE, FIDE, and AIP Contract Requirements M Appendix C - HIDE, FIDE, and AIP Contract Requirements Matrix.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.107 42 CFR 422.2 42 CFR 422.107(e)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10796	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10796	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10796	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 886

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	893	368	525
Annual IC Time Burden (Hours)	17,403	-5,029	22,432
Annual IC Cost Burden (Dollars)	0	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.

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