Medicare Advantage Model of Care Submission Requirements (CMS-10565)

Forms and Documents

Document Name	Status
Form CMS-10565 Tracking Face-to-Face Encounters (all SNP types) Form	Modified
Form CMS-10565 Off-cycle Submission Form	Modified
Form CMS-10565 Initial, Renewal, and Re-Submissions Form	Modified
CMS-10565 - Supporting Statement.docx Supporting Statement A	2025-06-25
MOC PRA 60-comments and response.docx Supplementary Document	2025-06-17
Crosswalk Attachment .docx Supplementary Document	2025-06-17

IC Document Collections

IC ID	Document Title	Status
247331	Training	Removed
247322	Tracking Face-to-Face Encounters (all SNP types) Form	Modified
218542	Off-cycle Submission Form	Modified
218541	Initial, Renewal, and Re-Submissions Form	Modified

ICR Details

OMB Control No: 0938-1296	ICR Reference No: 202506-0938-009
Status: Received in OIRA	Previous ICR Reference No: 202105-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Medicare Advantage Model of Care Submission Requirements (CMS-10565)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/30/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	1,915	0
Time Burden (Hours)	8,465	0
Cost Burden (Dollars)	0	0

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Abstract: Medicare Advantage (MA) Special Needs Plans (SNPs) are required to submit Models of Care (MOCs) as a component of the MA application process. The Affordable Care Act (ACA) requires that all SNPs be approved by the National Committee for Quality Assurance (NCQA). This approval is based on NCQA’s evaluation of SNPs using MOC scoring guidelines developed by CMS and NCQA for the Secretary of the Department of Health and Human Services (DHHS). The MOC elements cover the following areas: MOC 1- Description of the SNP Population; MOC 2 - Care Coordination; MOC 3 - Provider Network; and MOC 4 - Quality Measurement & Performance Improvement. SNPs submit a MOC at time of their initial application and based on their scores, SNPs receive an approval for a period of 1, 2 or 3 years. After the approval period expires, SNPs are required to submit an updated MOC for review for their renewal process. CMS is also developing a MOC off-cycle revision process so that SNPs can revise the MOC to modify its processes and strategies for providing care during their MOC approval period. CMS will require that SNPs submit summaries of their MOC revisions to CMS for NCQA evaluation when a SNP makes significant changes to its MOC during the approval period. NCQA will review the summary of changes to verify that the revisions are consistent with the acceptable, high quality standards as included in the original approved MOC. CMS will begin collecting MOCs mid-January 2016 to coincide with the MA Application collection.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 3205(e) Name of Law: The Patient Protection and Affordable Care Act (ACA)
   PL: Pub.L. 111 - 148 1859 (b)(6)(B)(iii) Name of Law: The Bipartisan Budget Act
  

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:
	90 FR 321	01/03/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 26591	06/23/2025
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Initial, Renewal, and Re-Submissions	CMS-10565	Model of Care Requirements for Medicare Advantage Special Needs Plans
Off-cycle Submission	CMS-10565	Model of Care Requirements for Medicare Advantage Special Needs Plans
Tracking Face-to-Face Encounters (all SNP types)	CMS-10565	Model of Care Requirements for Medicare Advantage Special Needs Plans
Training

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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	1,915	0	0	482	0	1,433
Annual Time Burden (Hours)	8,465	0	0	2,474	0	5,991
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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: CMS estimates a total of 8,465 hours for initial and renewal MOC submissions, annual MOC resubmissions for failure to meet the minimum benchmarks, the tracking of face-to-face encounters, off-cycle MOC submissions. This is an overall burden increase of 3,293 hours which accounts for all existing, revised and new MOC requirements. CMS adjusted the number of initial and renewal MOC submissions from 273 to 410 and the number of MOC resubmissions from 14 to 15. We adjusted the volume of off-cycle MOC submissions from 139 to 150. We also adjusted the number of SNPs tracking face-to-face encounters from 734 to 1340.

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Annual Cost to Federal Government: $1,098,956

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]? 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? 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: 06/30/2025

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