Applicable Integrated Plan Coverage Decision Letter

Applicable Integrated Plan Coverage Decision Letter (CMS-10716)

OMB: 0938-1386

IC ID: 241332

Documents and Forms
Document Name
Document Type
Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
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Applicable Integrated Plan Coverage Decision Letter
 
No Modified
 
Mandatory
 
42 CFR 422.631 42 CFR 422.561

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction CMS10716FormInstructions_2025_.docx Yes No Fillable Printable
Form and Instruction CMS-10716 Integrated Coverage Decision Letter DSNPCoverageDecisionLetterIntegrated_2025_.docx Yes Yes Fillable Printable
Form and Instruction CMS-10716 Integrated Coverage Decision Letter (Spanish) DSNPCoverageDecisionLetterIntegrated_2025_Spanish_.docx Yes Yes Fillable Printable

Health Health Care Services

 

129 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Requested 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 10,468 0 0 -14,248 0 24,716
Annual IC Time Burden (Hours) 1,745 0 0 -2,375 0 4,120
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Track Change - Form Instructions CMS10716FormInstructions_2025__redlined.pdf 07/22/2025
Track Change - DSNPCoverageDecisionLetterIntegrated DSNPCoverageDecisionLetterIntegrated_2025_redlined.pdf 07/22/2025
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