DEMONSTRATION PROJECT FOR CALCULATING ADJUSTED AVERAGE PER CAPITA COSTS FOR HMO'S

ICR 198001-0938-002

OMB: 0938-0092

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0092 198001-0938-002
Historical Active 197904-0938-003
HHS/CMS
DEMONSTRATION PROJECT FOR CALCULATING ADJUSTED AVERAGE PER CAPITA COSTS FOR HMO'S
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 01/25/1980
Retrieve Notice of Action (NOA) 01/04/1980
  Inventory as of this Action Requested Previously Approved
12/31/1980 12/31/1980
350 0 0
117 0 0
0 0 0

IN SEPTEMBER, 1978, HCFA AWARDED CONTRACTS TO CONDUCT DEMONSTRATIONS IN THE AREA OF PROSPECTIVE RISK REIMBURSEMENT TO HMO'S BASED ON PER CAPITA COSTS. IN ORDER TO CALCULATE THE PROPER REIMBURSEMENT, HCFA NEEDS THE NAMES AND SSNS OF ALL MEDICARE BENEFICIARIES RESIDING IN THE HMO'S SERVICE AREA WHO HAVE RESIDED IN LONG TERM CARE INSTITUTIONS FOR AT LEAST 30 DAYS.

None
None


No

1
IC Title Form No. Form Name
DEMONSTRATION PROJECT FOR CALCULATING ADJUSTED AVERAGE PER CAPITA COSTS FOR HMO'S HCFA-123-T,, 123-L

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 350 0 0 0 350 0
Annual Time Burden (Hours) 117 0 0 0 117 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
01/04/1980


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