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

Forms and Documents

Document Name	Status
Form CMS-10796 Appendix C - HIDE, FIDE, and AIP Contract Requirements Matrix Form and Instruction	Modified
Form CMS-10796 Appendix B - D-SNP State Medicaid Agency Contract Matrix.docx Form and Instruction	Modified
Form CMS-10796 D-SNP State Medicaid Agency(ies) Contract(s): Attestations Form and Instruction	Modified
Form CMS-10796 Dual Eligible Special Needs Plan Contract with the State Medicaid Agency Form and Instruction	Modified
CMS-10796 - Supporting Statement A.docx Supporting Statement A	2025-03-21
CMS-10796 - Supporting Statement A.docx Supporting Statement A	2025-03-21
UHC.pdf Public Comments	2025-01-21
SMAC PRA Comments Centene AHIP.pdf Public Comments	2025-01-21
MLTSS Association.pdf Public Comments	2025-01-21
Humana.pdf Public Comments	2025-01-21
SMAC PRA instrument Crosswalk - 30-Day Notice .docx Supplementary Document	2025-03-18
SMAC PRA instrument Crosswalk - 30-Day Notice .docx Supplementary Document	2025-03-18
CMS-10796 60-Day Comment Responses.docx Supplementary Document	2025-03-18
CMS-10796 60-Day Comment Responses.docx Supplementary Document	2025-03-18
SMAC PRA instrument crosswalk.pdf Supplementary Document	2025-03-18
SMAC PRA instrument crosswalk.pdf Supplementary Document	2025-03-18

IC Document Collections

IC ID	Document Title	Status
251117	Dual Eligible Special Needs Plan Contract with the State Medicaid Agency Form and Instruction	Modified	Appendix C - HIDE, FIDE, and AIP Contract Requirements Matrix
251117	Dual Eligible Special Needs Plan Contract with the State Medicaid Agency Form and Instruction	Modified	Appendix B - D-SNP State Medicaid Agency Contract Matrix.docx
251117	Dual Eligible Special Needs Plan Contract with the State Medicaid Agency Form and Instruction	Modified	D-SNP State Medicaid Agency(ies) Contract(s): Attestations
251117	Dual Eligible Special Needs Plan Contract with the State Medicaid Agency Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1410	ICR Reference No: 202503-0938-002
Status: Active	Previous ICR Reference No: 202206-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Dual Eligible Special Needs Plan Contract with the State Medicaid Agency (CMS-10796)
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: 03/28/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/28/2025
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2029	36 Months From Approved	03/31/2026
Responses	893	0	525
Time Burden (Hours)	17,403	0	22,432
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): PL: Pub.L. 115 - 123 50311(b) Name of Law: Bipartisan Budget Act of 2018
   PL: Pub.L. 108 - 173 1859(b)(6) and 1859(f)(3)(D) Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003
  

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:
	89 FR 92690	11/22/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 13368	03/21/2025
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
Dual Eligible Special Needs Plan Contract with the State Medicaid Agency	CMS-10796, CMS-10796, CMS-10796	D-SNP State Medicaid Agency(ies) Contract(s): Attestations ,   Appendix B - D-SNP State Medicaid Agency Contract Matrix.docx ,   Appendix C - HIDE, FIDE, and AIP Contract Requirements Matrix

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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	893	525	0	368	0	0
Annual Time Burden (Hours)	17,403	22,432	0	-5,029	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Burden has decreased due to the removal of multiple one time burdens that are no longer needed. This included a a one-time burden for each new applicable integrated plan to update its policies, procedures, and the D-SNP contract with the state Medicaid agency to reflect the new integrated organization determination and grievance procedures. The removal also included time/effort associated with State Medicaid agencies implement a one-time update to their systems and Plans implement a one-time update to their systems.

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Annual Cost to Federal Government: $146,327

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

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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: 03/28/2025

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