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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Medicare Advantage Applications - Part C
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
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
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-10237
PART C -MEDICARE ADVANTAGE
CMS-10237 2010DraftApplication-9308finalclean 3.doc
Yes
Yes
Paper Only
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
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-b
CMS10237-PartC-MA-APP-CLEANVERSION-12-4-08.doc
Yes
Yes
Paper Only
Other-c
CMS10237-PartC-MA-APP- Redlineversion- 12-4-08(aftercomments).doc
Yes
Yes
Paper Only
Other-d
Combined HSD 12-04-2008.xls
Yes
Yes
Paper 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:
267
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 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
Documents for IC
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.