Medicare Advantage Application - Part C and 1876 Cost Plan Expansion Application Regulations under 42 CFR 422 (Subpart K) & 417.400 (CMS-10237)

Forms and Documents

Document Name	Status
Clean version-DMAO Response to OMB Question Supporting Statement for Applications Passback3.docx Supporting Statement A	2016-01-14
Final CY 2017 Consolidated Public comment Part C App (response to 60day).pdf Supplementary Document	2015-09-29

IC Document Collections

IC ID	Document Title	Status
8785	Part C Medicare Advantage Application and 1876 Cost Plan Expansion Application Other-PRA Disclosure Statement	Modified

ICR Details

OMB Control No: 0938-0935	ICR Reference No: 201509-0938-013
Status: Historical Active	Previous ICR Reference No: 201410-0938-002
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 (CMS-10237)
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: 01/21/2016
	Date Received in OIRA: 09/30/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2019	36 Months From Approved	11/30/2017
Responses	500	0	566
Time Burden (Hours)	18,043	0	22,625
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. 108 - 173 1857 Name of Law: Medicare Advantage
   US Code: 42 USC 1395mm Name of Law: null
   PL: Pub.L. 110 - 275 161 Name of Law: Provisions relating to Part C
  

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:
	80 FR 38692	07/07/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 57616	09/24/2015
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 Application and 1876 Cost Plan Expansion Application	CMS-10237, CMS-10237, CMS-10237, CMS-10237	Part C - Medicare Advantage and 1876 Cost Plan Expansion Application ,   CY 2016 Medicare Advantage HSD Exception Request Template ,   Medicare Advantage Facility HSD Table ,   Medicare Advantage Provider HSD Table

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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	500	566	0	0	-66	0
Annual Time Burden (Hours)	18,043	22,625	0	0	-4,582	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: We have adjusted our cost estimates by using the most recent BLS wage estimates. The reduction of 699 hr in annual burden hours (22,625 hr - 21,926 hr = -699 hr) from CY 2016 to CY 2017 is attributed to the reduction in the estimated hours to complete both SNP with MA and SNP with SAE applications. The estimated hours for completion of a SNP application was 42 hours in CY2016 which was reduced to 39 hours in CY2017. Note the projected number of SNP applications remained unchanged from CY2016 to CY2017. There is a 3 hr increase in burden from the MA initial application and a 3 hr decrease for the SNP Proposal for CY2017. Thus, the increase and decrease in burden hours cancel each other.

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Annual Cost to Federal Government: $1,770,600

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]? No

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: 09/30/2015

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