Off-cycle Submission

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

Documents and Forms

Document Name Document Type
Form CMS-10565 Off-cycle Submission Form
CMS-10565 Model of Care Requirements for Medicare Advantage Specia Draft MOC Matrix Requirements.docx Form
Dratf MOC Matrix Requirements_ TC.docx Track Change MOC Requirments IC Document

Information Collection (IC) Details

IC Title:	Off-cycle Submission	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 422.101(f)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10565	Model of Care Requirements for Medicare Advantage Special Needs Plans	Draft MOC Matrix Requirements.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	150	11	139
Annual IC Time Burden (Hours)	600	44	556
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Track Change MOC Requirments	Dratf MOC Matrix Requirements_ TC.docx	06/17/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.