Information Collection

Initial, Renewal, and Re-Submissions

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10565				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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
60-day Track Change MOC Matrix Req		08/25/2025
30-day Track Change MOC Matrix Req		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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