Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits (CMS-10237)

Forms and Documents

Document Name	Status
Form CMS-10237 Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits Form and Instruction	Modified
Summary of Changes.pdf Supplementary Document	2020-01-06
CY 2021 Consolidated Public comments for 60 day Part C App.xlsx Supplementary Document	2020-01-06
Supporting Statement 508.docx Supporting Statement A	2020-01-06

IC Document Collections

IC ID	Document Title	Status
8785	Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0935	ICR Reference No: 202001-0938-001
Status: Received in OIRA	Previous ICR Reference No: 201901-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits (CMS-10237)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/07/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved	03/31/2022
Responses	435	400
Time Burden (Hours)	6,754	6,106
Cost Burden (Dollars)	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): US Code: 42 USC 1395mm Name of Law: null
   PL: Pub.L. 110 - 275 161 Name of Law: Provisions relating to Part C
   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:
	84 FR 48145	09/12/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 506	01/06/2020
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
Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits	CMS-10237	CY 2021 Part C -Medicare Advantage and 1876 Cost Plan Expansion Application

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ICR Summary of Burden

	Total Request	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	435	400	0	35	0	0
Annual Time Burden (Hours)	6,754	6,106	0	648	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: Collection has increased in burden due to an increase in received applications. The program believes this increase was caused by the industry preparedness.

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Annual Cost to Federal Government: $1,041,564

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: 01/07/2020

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