OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Dual Eligible Special Needs Plan Contract with the State Medicaid Agency (CMS-10796)

OMB 0938-1410 · HHS/CMS.

OMB 0938-1410

Medicare Advantage (MA) organizations with D-SNPs and States use the information in the contract to provide benefits, or arrange for the provision of Medicaid benefits, to which an enrollee is entitled. CMS reviews the D-SNP contract with the State Medicaid agency to ensure that it meets the requirements at § 422.107.

The latest form for Dual Eligible Special Needs Plan Contract with the State Medicaid Agency (CMS-10796) expires 2029-03-31 and is listed under ICR 202503-0938-002.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-10796 Appendix C - HIDE, FIDE, and AIP Contract Requirements MatrixForm and Instruction
Form CMS-10796 Appendix B - D-SNP State Medicaid Agency Contract Matrix.docxForm and Instruction
Form CMS-10796 D-SNP State Medicaid Agency(ies) Contract(s): AttestationsForm and Instruction
Form CMS-10796 Dual Eligible Special Needs Plan Contract with the State Medicaid AgencyForm and Instruction
CMS-10796 - Supporting Statement A.docxSupporting Statement A
CMS-10796 - Supporting Statement A.docxSupporting Statement A
UHC.pdfPublic Comments
SMAC PRA Comments Centene AHIP.pdfPublic Comments
MLTSS Association.pdfPublic Comments
Humana.pdfPublic Comments
SMAC PRA instrument Crosswalk - 30-Day Notice .docxSupplementary Document
SMAC PRA instrument Crosswalk - 30-Day Notice .docx Supplementary Document
CMS-10796 60-Day Comment Responses.docxSupplementary Document
CMS-10796 60-Day Comment Responses.docx Supplementary Document
SMAC PRA instrument crosswalk.pdfSupplementary Document
SMAC PRA instrument crosswalk.pdf Supplementary Document
Dual Eligible Special Needs Plan Contract with the State Medicaid Agency Form and Instruction
Dual Eligible Special Needs Plan Contract with the State Medicaid Agency Form and Instruction
Dual Eligible Special Needs Plan Contract with the State Medicaid Agency Form and Instruction
Dual Eligible Special Needs Plan Contract with the State Medicaid Agency Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202503-0938-002 Revision of a currently approved collection 2025-03-28
202206-0938-002 New collection (Request for a new OMB Control Number) 2022-06-01 Approved without change
202201-0938-009 New collection (Request for a new OMB Control Number) 2022-01-13 Comment filed on proposed rule