OMB control number

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

OMB 0938-1410 · HHS/CMS.

OMB 0938-1410

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.

The latest form for Dual Eligible Special Needs Plan Contract with the State Medicaid Agency (CMS-10796) expires 2029-03-31 and can be found here.

Latest Forms, Documents, and Supporting Material

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

All Historical Document Collections

202503-0938-002	Revision of a currently approved collection	2025-03-28
202206-0938-002 Approved without change	New collection (Request for a new OMB Control Number)	2022-06-01
202201-0938-009 Comment filed on proposed rule	New collection (Request for a new OMB Control Number)	2022-01-13