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

Forms and Documents

Document Name	Status
Form CMS-10237 Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012) Form and Instruction	Modified
UHC_Comments_for_Part_C_Application(1) (CMS-10237).xlsx Supplementary Document	2012-12-19
UCare_Comments_CMS-10237[1].pdf Supplementary Document	2012-12-19
2014 Consolidated Public comment Part C App (response to 60day)(09122012).xlsx Supplementary Document	2012-12-19
2014 High Levels Summary of Changes 9-17-12(30-day)(Final Draft) .pdf Supplementary Document	2012-11-21
2014 Consolidated Public comment Part C App (response to 60day)(09132012).pdf Supplementary Document	2012-11-21
Supporting Statement for CY 2014 Applications(Final) 12-19-12.docx Supporting Statement A	2012-12-19

IC Document Collections

IC ID	Document Title	Status
8785	Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0935	ICR Reference No: 201211-0938-007
Status: Historical Active	Previous ICR Reference No: 201111-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Advantage Application - Part C and 1876 Cost Plan Expansion Application regulations under 42 CFR 422 subpart K & 417.400
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/20/2012
	Date Received in OIRA: 11/21/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	36 Months From Approved	01/31/2015
Responses	566	0	378
Time Burden (Hours)	21,581	0	13,296
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): PL: Pub.L. 110 - 275 161 Name of Law: Provisions relating to Part C
   US Code: 42 USC 1395mm Name of Law: null
   PL: Pub.L. 108 - 173 1857 Name of Law: Medicare Advantage
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 40064	07/06/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 62241	10/12/2012
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)	CMS-10237, CMS-10237, CMS-10237, CMS-10237	CY 2014 HSD Exception Request Template ,   MA Facility Table 2014 ,   .PartC MA and Cost Plan Applications ,   MA Provider Table CY 2014

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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	566	378	0	0	188	0
Annual Time Burden (Hours)	21,581	13,296	0	8,285	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: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: Increase Burden Hours per Special Needs Plan (SNP) application: For CY2014, CMS added one (1) new matrix to facilitate the contract review process for Fully-Integrated Dual Eligible (FIDE) Special Needs Plans (SNPs). Revisions were also made to the End Stage Renal Disease (ESRD) Waiver to ensure the collection of required information from SNPs applying for this waiver. An additional two (2) hours of burden was added to the SNP Medicare Advantage (MA) and SNP Service Area Expansion (SAE) applications. CMS also added two templates and an attestation to request that Medicare Advantage Organizations (MAOs) describe how enrollees will have equal access to specified tiered medical benefits. An additional 12 hours of burden was added to the initial MA Applications. Increase in Overall Burden of Hours and Respondents: Although seven (7) contract attestations and three (3) templates were removed as a part of a lean process improvement to collect fewer documents from the applicants and require less review by CMS staff, the overall burden hours increased because of the increase in the expected number of respondents and the addition of matrices, templates, and attestations. An internal assessment of the number of respondents resulted in a higher projection for CY 2014.

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Annual Cost to Federal Government: $948,400

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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 11/21/2012

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