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OMB Control No: 0938-0165	ICR Reference No: 202507-0938-025
Status: Received in OIRA	Previous ICR Reference No: 202203-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: OFM
Title: Prepaid Health Plan Cost Report (CMS-276)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 07/29/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2025
Responses	36	51
Time Burden (Hours)	1,128	1,612
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	36	51	-15
Annual Time Burden (Hours)	1,128	1,612	-484
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This iteration proposes minor changes to the worksheets and instructions (see the attached Crosswalks for details). The changes have no impact on our per response time estimates. Since our last submission to OMB, two cost-based MCOs have terminated, which has affected the estimated total number of respondents. As a result, the estimated number of respondents for HMO/CMPs have been reduced by minus 3 (from 9 to 6) since our last submission, and the number of respondents for HCPPs have been reduced by minus 2 (from 8 to 6). As such, our total time estimate decreased by minus 484 hours (from 1,612 hr to 1,128 hr).

Annual Cost to Federal Government: $38,688

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov