Information Collection

Applicable Integrated Plan Coverage Decision Letter

IC 241332 under ICR 202507-0938-022 · OMB 0938-1386.

Documents and Forms

Document Name Document Type
Form CMS-10716 Integrated Coverage Decision Letter Applicable Integrated Plan Coverage Decision Letter Form and Instruction
Form CMS-10716 Integrated Coverage Decision Letter (Spanish) Applicable Integrated Plan Coverage Decision Letter Form and Instruction
CMS10716FormInstructions_2025_.docx Instruction
CMS10716FormInstructions_2025_.docx Instruction
CMS-10716 Integrated Coverage Decision Letter DSNPCoverageDecisionLetterIntegrated_2025_.docx Form and Instruction
CMS-10716 Integrated Coverage Decision Letter DSNPCoverageDecisionLetterIntegrated_2025_.docx Form and Instruction
CMS-10716 Integrated Coverage Decision Letter (Spanish) DSNPCoverageDecisionLetterIntegrated_2025_Spanish_.docx Form and Instruction
CMS-10716 Integrated Coverage Decision Letter (Spanish) DSNPCoverageDecisionLetterIntegrated_2025_Spanish_.docx Form and Instruction
CMS10716FormInstructions_2025__redlined.pdf Track Change - Form Instructions IC Document
CMS10716FormInstructions_2025__redlined.pdf Track Change - Form Instructions IC Document
DSNPCoverageDecisionLetterIntegrated_2025_redlined.pdf Track Change - DSNPCoverageDecisionLetterIntegrated IC Document
DSNPCoverageDecisionLetterIntegrated_2025_redlined.pdf Track Change - DSNPCoverageDecisionLetterIntegrated IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Applicable Integrated Plan Coverage Decision Letter	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.631 42 CFR 422.561

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 129	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,468	-14,248	24,716
Annual IC Time Burden (Hours)	1,745	-2,375	4,120
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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

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

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