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Federal forms, ICRs, and supporting documents

Information Collection

Off-cycle Submission

IC 218542 under ICR 202506-0938-009 · OMB 0938-1296.

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Off-cycle Submission
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 422.101(f)

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

Health Health Care Services

 

150 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 150 0 11 0 139 0
Annual IC Time Burden (Hours) 600 0 44 0 556 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
60-day Track Change MOC Requirments 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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