Information Collection

Part C Medicare Advantage Application and 1876 Cost Plan Expansion Application

IC 8785 under ICR 201610-0938-011 · OMB 0938-0935.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0935 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10237 Part C Medicare Advantage Application and 1876 Cost Plan Expansion Application Form and Instruction
CY 2018 HSD Instructions -30 Day 10-20-16.pdf Instruction
CMS-10237 CY 2018 Part C - Medicare Advantage and 1876 Cost Plan E CY2018 Part C - MA and 1876 Cost Plan Expansion Application-30-day 10-20-16.pdf Form and Instruction
CMS-10237 CY 2018 Medicare Advantage HSD Exception Request Templat CY 2018 Exception Request Template - 30 day 10-20-16 pdf.pdf Form
CMS-10237 CY 2018 Medicare Advantage Facility HSD Table CY2018 CMS MA Facility HSD Table 10-20-16.pdf Form
CMS-10237 CY 2018 Medicare Advantage Provider HSD Table CY2018 CMS MA Provider HSD Table 10-20-16 .pdf Form
CY 2018 High Level Summary of Changes- 30 day 10-13.pdf Crosswalk IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Part C Medicare Advantage Application and 1876 Cost Plan Expansion Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.501 42 CFR 422.503 42 CFR 422.504 42 CFR 422.508 42 CFR 422.510 42 CFR 422.512 42 CFR 422.516 42 CFR 422.500 42 CFR 422.502 42 CFR 417.400 42 CFR 422.506 42 CFR 422.505 42 CFR 422.514 42 CFR 422.520 42 CFR 422.521 42 CFR 422.524 42 CFR 422.527

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10237	CY 2018 Part C - Medicare Advantage and 1876 Cost Plan Expansion Application	CY2018 Part C - MA and 1876 Cost Plan Expansion Application-30-day 10-20-16.pdf	Yes	Yes	Fillable Printable
Instruction			CY 2018 HSD Instructions -30 Day 10-20-16.pdf	Yes	No	Fillable Printable
Form	CMS-10237	CY 2018 Medicare Advantage HSD Exception Request Template	CY 2018 Exception Request Template - 30 day 10-20-16 pdf.pdf	Yes	Yes	Fillable Printable
Form	CMS-10237	CY 2018 Medicare Advantage Facility HSD Table	CY2018 CMS MA Facility HSD Table 10-20-16.pdf	Yes	Yes	Fillable Printable
Form	CMS-10237	CY 2018 Medicare Advantage Provider HSD Table	CY2018 CMS MA Provider HSD Table 10-20-16 .pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 310	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	310	-190	500
Annual IC Time Burden (Hours)	10,941	-7,102	18,043
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	CY 2018 High Level Summary of Changes- 30 day 10-13.pdf	11/03/2016

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