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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Alternative Benefit Plan (ABP)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR 430.12
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-10434
ABP
ABP Form.pdf
Yes
Yes
Fillable Fileable
Instruction
AB Plans General Background 111612.docx
Yes
No
Printable Only
Instruction
B1 AB Plans Amendement_Draft_111912.docx
Yes
No
Printable Only
Instruction
B2 AB Plans Populations_Draft_111912.docx
Yes
No
Printable Only
Instruction
B3a AB Plan Vol Assurances_Draft_111912.docx
Yes
No
Printable Only
Instruction
B3b AB Plans Mand Assurances_Draft_111912.docx
Yes
No
Printable Only
Instruction
B4 AB Plans Select-Cost Shar_Draft_111912.docx
Yes
No
Printable Only
Instruction
B4a,b,c ABP Benefit Packages_Draft_111912.docx
Yes
No
Printable Only
Instruction
B4d ABP Sec-Approved Package_Draft_111612.docx
Yes
No
Printable Only
Instruction
B5 AB Plan Benefit Assurances_Draft_111912.docx
Yes
No
Printable Only
Instruction
B6 ABP Benchmark Equiv_Draft_111912.docx
Yes
No
Printable Only
Instruction
B7 ABP Benchmark Equiv Assur_Draft_111912.docx
Yes
No
Printable Only
Instruction
B8 ABP Service Del Systems_Draft_111912.docx
Yes
No
Printable Only
Instruction
B9 ABP Employer Spon Ins_Draft_111912.docx
Yes
No
Printable Only
Instruction
B10 ABP General Assurances_Draft_111912.docx
Yes
No
Printable Only
Instruction
B11,12,13 ABP Admin Table_Draft_111912.docx
Yes
No
Printable Only
Instruction
B14 ABP Base Benchmark Admin_Draft_111912.docx
Yes
No
Printable Only
Instruction
B15 ABP Termination Phase Out_Draft_111912.docx
Yes
No
Printable Only
Instruction
B16 ABP Payment Methodologies_Draft_111912.docx
Yes
No
Printable Only
Instruction
B17 ABP State Benefits Table_Draft_111912.docx
Yes
No
Printable Only
Instruction
B18 AB Plan Components_Draft_111912.docx
Yes
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
56
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
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
56
0
56
0
0
0
Annual IC Time Burden (Hours)
728
0
728
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
ABP - Webinar Transcript
ABP Webinar.pdf
01/09/2013
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.