OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Medicare Advantage Application - Part C and 1876 Cost Plan Expansion Application regulations under 42 CFR 422 subpart K & 417.400

ICR 201009-0938-017 · OMB 0938-0935 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CMS-10237 Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012) Form and Instruction Modified Available
2012 PRA CommentTracking (Response to 60 daynotice).xls Supplementary Document Uploaded 2010-09-17 Repair queued
2012 High Level Sum- Changes from 60 Comment Period_V3_Rev_1.docx Supplementary Document Uploaded 2010-09-17 Available
CMS MA Signature Authority Grid (2012 Draft).xls Supplementary Document Uploaded 2010-09-17 Available
CMS MA Provider Table (2012 Draft).xls Supplementary Document Uploaded 2010-09-17 Repair queued
CMS MA Facility Table (2012 Draft).xls Supplementary Document Uploaded 2010-09-17 Available
2012 Draft HSD Instructions Clean (PRA-30daynotice).doc Supplementary Document Uploaded 2010-09-17 Repair queued
CMS MA Contract and Signature Index-Facilities (2012 Draft).xls Supplementary Document Uploaded 2010-09-17 Repair queued
CMS MA Additional and Supplment Benefits Table (2012 Draft).xls Supplementary Document Uploaded 2010-09-17 Repair queued
Supporting Statement for 2012 Applications(30 daycomment).doc Supporting Statement A Uploaded 2010-09-17 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
8785 Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012) Form and Instruction Modified
ICR Details
0938-0935 201009-0938-017
Historical Active 200910-0938-008
HHS/CMS
Medicare Advantage Application - Part C and 1876 Cost Plan Expansion Application regulations under 42 CFR 422 subpart K & 417.400
Revision of a currently approved collection   No
Regular
Approved without change 12/20/2010
Retrieve Notice of Action (NOA) 09/30/2010
Consistent with the PRA, this ICR should be re-submitted along with the publication of any draft "forthcoming guidance" documents to the extent that such guidance documents would result in new information collection, recordkeeping, or disclosure requirements or result in changes to burden or capital cost from existing requirements.
  Inventory as of this Action Requested Previously Approved
12/31/2011 36 Months From Approved 01/31/2011
870 0 291
15,696 0 9,547
0 0 0
In order to provide health benefits to Medicare beneficiaries under the Medicare Advantage Program and/or the 1876 Cost Plan, applicant must meet regulatory requirements to enter into a contract with CMS, or to continue to contract with CMS. The revised Part C application is created to capture the applicants' information.
PL: Pub.L. 108 - 173 1857 Name of Law: Medicare Advantage
   PL: Pub.L. 110 - 275 161 Name of Law: Provisions relating to Part C
   US Code: 42 USC 1395mm Name of Law: null
  
None
0938-AP77 Final or interim final rulemaking 75 FR 19803 04/15/2010
  75 FR 33308 06/11/2010
75 FR 57035 09/17/2010
Yes
  Total Approved 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 870 291 0 579 0 0
Annual Time Burden (Hours) 15,696 9,547 0 6,149 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Changing Regulations
No
Increase in respondents: For contract year 2012, CMS expects a slight increase in initial applicants and SAE applications based on CY 2011 application submissions, and a major increase in the number SNP proposal submissions. Increase Burden of Hours: An additional 2 hours of burden was added to the base MA application. This increase stems from changes in regulations at 42 CFR 422 with regards to the compliance plans and quality improvement plans. CMS made an internal decision to have organizations' submit its compliance plan and quality improvement program plans as a part of the application process. CMS believes having this information will help us evaluation an organization understanding of the MA programs and the organization's readiness to serve beneficiaries as a MA contractor. CMS has also made an internal decision to have MA contractors that are currently offering a SNP product to complete and submit a modified SNP proposal. CMS believes having this information will help us better evaluate the quality of health care being offered across all SNP programs.
$2,877,000
No
No
No
No
No
Uncollected
Bonnie Harkless 4107865666
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
09/30/2010