Medicare Advantage Applications

Forms and Documents

Document Name	Status
Form CMS-10135 Medicare Advantage Applications Form and Instruction	Modified
RPPO's Essential.doc Supplementary Document	2006-08-22
PFFS License.doc Supplementary Document	2006-08-22
Matrixadm.DOC Supplementary Document	2006-08-22
Matrixadm.DOC Supplementary Document	2006-08-22
Matrix1.doc Supplementary Document	2006-08-22
Legal-2 and Instructions.xls Supplementary Document	2006-08-22
Legal-1.doc Supplementary Document	2006-08-22
HSD.XLS Supplementary Document	2006-08-22
Guidelines for all applications.DOC Supplementary Document	2006-08-22
CMS 10136 Final Revision Matrix.xls Supplementary Document	2006-08-22
Cert and Instructions.doc Supplementary Document	2006-08-22
CMS 10117,10118,10119,10135, 10135 - 021706 Supporting Statement.DOC Supporting Statement A	2006-08-22

IC Document Collections

IC ID	Document Title	Status
8785	Medicare Advantage Applications Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0935	ICR Reference No: 200608-0938-002
Status: Historical Active	Previous ICR Reference No: 200512-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Advantage Applications
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/21/2006
	Date Received in OIRA: 08/22/2006
Terms of Clearance: CMS will update the burden and number of responses in accordance with any annual changes that occur during the MA contract period.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2008	36 Months From Approved	11/30/2006
Responses	110	0	90
Time Burden (Hours)	3,400	0	2,770
Cost Burden (Dollars)	0	0	0

---

Abstract: Health plans must meet certain regulatory requirements to enter into a contract with CMS to provide health benefits to Medicare beneficiaries. These applications are the collection forms to obtain the information from a health plan that will allow CMS staff to determine compliance with the regulations.

---

Authorizing Statute(s): PL: Pub.L. 108 - 173 1857 Name of Law: Contracts with Medicare+Choice Organizations
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 33459	06/09/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 42850	07/28/2006
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Medicare Advantage Applications	CMS-10117, CMS-10136, CMS-10135, CMS-10119, CMS-10118	SAE Application and Instructions ,   CCP Application ,   MSA Application ,   MSA Application ,   RPPO Application

---

ICR Summary of Burden

	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	110	90	0	20	0	0
Annual Time Burden (Hours)	3,400	2,770	0	630	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

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

Burden Reduction Due to:

Short Statement: The burden change for this package is due to the response to questions from potential 2007 applications related to CMS-10136. Revisions were made to that application type after the emergency approval was granted.

---

Annual Cost to Federal Government: $1,273,440

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(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: 08/22/2006

---