Information Collection

Initial, Renewal, and Re-Submissions

IC 218541 under ICR 202506-0938-009 · OMB 0938-1296.

Documents and Forms

Document Name Document Type
Form CMS-10565 Initial, Renewal, and Re-Submissions Form
Form CMS-10565 Model of Care Requirements for Medicare Advantage Special Needs Plans Initial, Renewal, and Re-Submissions Form
CMS-10565 Model of Care Requirements for Medicare Advantage Specia Draft MOC Matrix Requirements.docx Form
CMS-10565 Model of Care Requirements for Medicare Advantage Specia MOC Matrix Requirements_final version.docx Form
Dratf MOC Matrix Requirements_ TC.docx Track Change MOC Matrix Req IC Document
Dratf MOC Matrix Requirements_ TC.pdf 60-day Track Change MOC Matrix Req IC Document
Updated 30-day MOC Matrix Requirements_redlined.pdf 30-day Track Change MOC Matrix Req IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Initial, Renewal, and Re-Submissions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10565	Model of Care Requirements for Medicare Advantage Special Needs Plans	MOC Matrix Requirements_final version.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 425	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 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	425	138	287
Annual IC Time Burden (Hours)	2,505	825	1,680
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
60-day Track Change MOC Matrix Req	Dratf MOC Matrix Requirements_ TC.pdf	08/25/2025
30-day Track Change MOC Matrix Req	Updated 30-day MOC Matrix Requirements_redlined.pdf	08/25/2025

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

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