Applicable Integrated Plan Coverage Decision Letter (CMS-10716)

Forms and Documents

Document Name	Status
CMS-10716_SupportingStatement_.docx Supporting Statement A	2025-07-28
CMS-10716 60-Day Comment Responses.docx Supplementary Document	2025-07-24
Crosswalk of changes to CDL and Form Instructions_.docx Supplementary Document	2025-07-22
Crosswalk of Changes to CDL.pdf Supplementary Document	2025-07-22

IC Document Collections

IC ID	Document Title	Status
241332	Applicable Integrated Plan Coverage Decision Letter Instruction	Modified

ICR Details

OMB Control No: 0938-1386	ICR Reference No: 202507-0938-022
Status: Received in OIRA	Previous ICR Reference No: 202404-0938-023
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Applicable Integrated Plan Coverage Decision Letter (CMS-10716)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/28/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	11/30/2025
Responses	10,468	24,716
Time Burden (Hours)	1,745	4,120
Cost Burden (Dollars)	0	0

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Abstract: This information collection request is for the “Applicable Integrated Plan Coverage Decision Letter” or the “coverage decision letter” will be issued as a result of an integrated organization determination under 42 CFR 422.631, when an applicable integrated plan reduces, stops, suspends, or denies, in whole or in part, a request for a service/item (including a Part B drug) or a request for payment of a service/item (including a Part B drug) the member has already received. “Applicable integrated plans” are defined at 42 CFR 422.561 as full integrated dual special needs plans (FIDE SNPs) and highly integrated dual special needs plans (HIDE SNPs) with exclusively aligned enrollment, where state policy limits the D-SNP’s membership to a Medicaid managed care plan offered by the same organization. These plans will issue the coverage decision letter starting in CY 2021 in place of the Notice of Denial of Medical Coverage (or Payment) (NDMCP) form (CMS-10003) as part of requirements to unify appeals and grievance processes.

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Authorizing Statute(s): PL: Pub.L. 115 - 123 50311(b) Name of Law: Bipartisan Budget Act of 2018
   US Code: 42 USC 1395w–28
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 13367	03/21/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 35529	07/28/2025
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Applicable Integrated Plan Coverage Decision Letter	CMS-10716, CMS-10716	Integrated Coverage Decision Letter ,   Integrated Coverage Decision Letter (Spanish)

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	10,468	24,716	0	0	-14,248	0
Annual Time Burden (Hours)	1,745	4,120	0	0	-2,375	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: Burden decreased in this collection is due to an error made in the data used for the previous package that included adverse, partially favorable, and fully favorable appeal decisions. The data should have only included adverse and partially favorable decisions; thus, the appeal number was higher leading to a higher burden erroneously. The overall number of applicable integrated plans and enrollees increased. In 2023, there were 112 applicable integrated plans with 810,377 enrollees. In 2025, there are 129 applicable integrated plans with 1,163,067 enrollees. The total number of hours is now 1,745.

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Annual Cost to Federal Government: $6,523

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: 07/28/2025

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