OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Medicare Advantage Applications - Part C

IC 8785 under ICR 200809-0938-012 · OMB 0938-0935.

Documents and Forms
Document Name
Document Type
Other-redline
Other-redline
Other-redline
Other-5
Other-a
Other-b
Other-b
Other-c
Other-d
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

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Medicare Advantage Applications - Part C
 
No Modified
 
Mandatory
 
42 CFR 422.524 42 CFR 422.527 42 CFR 422.502 42 CFR 422.505 42 CFR 422.514 42 CFR 422.520 42 CFR 422.501 42 CFR 422.503 42 CFR 422.504 42 CFR 422.506 42 CFR 422.508 42 CFR 422.510 42 CFR 422.512 42 CFR 422.516 42 CFR 422.500 42 CFR 422.521

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-redline CMS-10237 2010DraftApplication-9208finalredlinever 3.doc Yes Yes Paper Only
Form and Instruction CMS-10214 2010 INITIAL APPLICATION FOR Employer/Union Direct Contract PFFS MAO CMS-10214 2009 Direct Contract MAO Applicationfinal.docm Yes Yes Paper Only
Other-redline CMS-10214 2009 Direct Contract MAO Applicationredline.docm Yes Yes Paper Only
Form and Instruction CMS-10214 2010 Application Instructions for MA Organizations to Offer New Employer/Union-Only Group Waiver Plans (EGWPs) CMS-10214 2009 EGWP MAO Application_Final _part c cleanbb1.doc Yes Yes Paper Only
Other-redline CMS-10214 2009 EGWP MAO Application_Finalbb.doc Yes Yes Paper Only
Form and Instruction CMS-10237 PART C -MEDICARE ADVANTAGE CMS-10237 2010DraftApplication-9308finalclean 3.doc Yes Yes Paper Only
Other-c CMS10237-PartC-MA-APP- Redlineversion- 12-4-08(aftercomments).doc Yes Yes Paper Only
Other-5 High level Summ_2010_Application_Revisions_12-05-2008.doc Yes Yes Paper Only
Other-a CMS-10214 2009 EGWP MAO Applicationfinal1125(cleanversion).doc Yes Yes Paper Only
Other-b CMS-10214 2009 EGWP MAO Applicationredline1125(3).doc Yes Yes Paper Only
Other-d Combined HSD 12-04-2008.xls Yes Yes Paper Only
Other-b CMS10237-PartC-MA-APP-CLEANVERSION-12-4-08.doc Yes Yes Paper Only

Health Health Care Services

 

267 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 267 10 16 0 0 241
Annual IC Time Burden (Hours) 6,490 222 410 0 0 5,858
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS Admin-Management-Contract Matrix CMS Admin-Management-Contract Matrix.DOC 09/08/2008
HFLC_CMS State Certification_082208 (comments) HFLC_CMS State Certification_082208 (comments).doc 09/08/2008
High level Summ_2010_Application_Revisions_090308 High level Summ_2010_Application_Revisions_090308.doc 09/08/2008
LC-DraftAdminContract Matrix8-13-08clean (3) LC-DraftAdminContract Matrix8-13-08clean (3).doc 09/08/2008
LC-DraftRevisedProvider Contract Matrix9208final (2) LC-DraftRevisedProvider Contract Matrix9208final (2).doc 09/08/2008
Revised HSD 1MARKUP Revised HSD 1MARKUP.XLS 09/08/2008
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.