View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

Medicare Advantage Applications
 
No Modified
 
Voluntary
 
42 CFR 422.501

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10117 CCP Yes Yes Paper Only
Form and Instruction CMS-10118 PFFS Yes Yes Paper Only
Form and Instruction CMS-10119 RPPO Yes Yes Paper Only
Form and Instruction CMS-10135 SAE Yes Yes Paper Only
Form and Instruction CMS-10136 MSA Yes Yes Paper Only
Form and Instruction CMS-10214 EGWP Yes Yes Paper Only
Form and Instruction CMS-10117,10118,10119,10135,10136,10214 Yes Yes Paper Only

Health Health Care Services

 

220 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   50 %

  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 220 0 110 0 0 110
Annual IC Time Burden (Hours) 5,580 0 2,180 0 0 3,400
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Emergency Justification 12/08/2006
Cert 01/19/2007
Clean Cert 01/19/2007
Clean Draft 2008 MA Application Guidelines 01/19/2007
Clean HSD 01/19/2007
Clean Legal-1 01/19/2007
Clean Legal 2 01/19/2007
Clean Matrix 1 01/19/2007
Clean Matrix 2 01/19/2007
Clea Matrix ADM 01/19/2007
Draft 2008 CCP App 01/19/2007
Clean Draft 2008 CCP App 01/19/2007
Clean Draft 2008 PFFS App 01/19/2007
Clean State License 01/19/2007
Draft 2008 PFFS App 01/19/2007
License 01/19/2007
Clean Draft RPPO App 01/19/2007
Clean Essential Hospital Designation 01/19/2007
Draft RPPO App 01/19/2007
Essential 01/19/2007
Clean Draft SAE App 01/19/2007
Draft SAE App 01/19/2007
Clean Draft MSA App 01/19/2007
Clean Draft MSA Demo App 01/19/2007
Draft MSA App 01/19/2007
Draft MSA Demo App 01/19/2007
MAO App Redline 01/19/2007
PFFS App Redline 01/19/2007
Clean MAO App 01/19/2007
Clean PFFS App 01/19/2007
MA App Guidelines 01/19/2007
HSD 01/19/2007
Legal 1 01/19/2007
Legal 2 01/19/2007
Matrix 1 01/19/2007
Matrix 2 01/19/2007
Matrix ADM 01/19/2007
Final 2008 MA CCP Application cert (final2008) 01/31/2007
Final 2008 MA CCP Application HSD (final2008) 01/31/2007
Final 2008 MA CCP Application legal-1 (final2008) 01/31/2007
Final 2008 MA CCP Application legal-2(final2008) 01/31/2007
Final 2008 MA CCP Application matrix1(final2008) 01/31/2007
Final 2008 MA CCP Application matrix2 (final2008) 01/31/2007
Final 2008 MA CCP Application matrixadm (final2008). 01/31/2007
Final 2008 MA CCP Application Final 2008 CCP application 1-07 01/31/2007
Final 2008 MA CCP Application Final 2008 MA application Guidelines 1-07 01/31/2007
Final 2008 MA MSA Application cert (final2008) 01/31/2007
Final 2008 MA MSA Application Final 2008 MA application Guidelines 1-07 01/31/2007
Final 2008 MA MSA Application FINAL 2008 MSA Demo App 1-07 01/31/2007
Final 2008 MA MSA Application Final 2008 MSA Application 1-07 01/31/2007
Final 2008 MA MSA Application legal-1 (final2008) 01/31/2007
Final 2008 MA MSA Application matrixadm (final2008) 01/31/2007
Final 2008 MA PFFS Application cert (final2008) 01/31/2007
Final 2008 MA PFFS Application Final 2008 MA application Guidelines 1-07 01/31/2007
Final 2008 MA PFFS Application\Final 2008 MA PFFS Application-1-07 01/31/2007
Final 2008 MA PFFS Application\HSD (final2008). 01/31/2007
Final 2008 MA PFFS Application\legal-1.(final2008). 01/31/2007
Final 2008 MA PFFS Application\legal-2 (final2008) 01/31/2007
Final 2008 MA PFFS Application\license (final2008). 01/31/2007
Final 2008 MA PFFS Application\matrix1(final2008) 01/31/2007
Final 2008 MA PFFS Application\matrix2(final2008 01/31/2007
Final 2008 MA PFFS Application\matrixadm (final2008) 01/31/2007
Final 2008 RPPO Application\cert (final2008) 01/31/2007
Final 2008 RPPO Application\essential (final2008) 01/31/2007
Final 2008 RPPO Application\Final 2008 MA application Guidelines 1-07 01/31/2007
Final 2008 RPPO Application\FINAL 2008 RPPO Application 1-07 01/31/2007
Final 2008 RPPO Application\HSD (final2008) 01/31/2007
Final 2008 RPPO Application\legal-1.(final2008 01/31/2007
Final 2008 RPPO Application\legal-2 (final2008) 01/31/2007
Final 2008 RPPO Application\matrix1(final2008 01/31/2007
Final 2008 RPPO Application\matrix2(final2008) 01/31/2007
Final 2008 RPPO Application\matrixadm (final2008) 01/31/2007
Final MA\cert (final2008) 01/31/2007
Final MA\Final 2008 MA application Guidelines 1-07 01/31/2007
Final MA\Final 2008 SAE Application 1-07 01/31/2007
Final MA\HSD (final2008) 01/31/2007
Final MA\legal-1.(final2008) 01/31/2007
Final MA\legal-2 (final2008). 01/31/2007
Final MA\matrix1(final2008) 01/31/2007
Final MA\matrix2(final2008) 01/31/2007
Final MA\matrixadm (final2008) 01/31/2007
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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