Information Collection

Information Collection Requirements In 42 Cfr Part 434, Subparts A Thru E, Medicaid Contracts With Health Maintenance Organizations (hmos) & Prepaid Health Plans

IC 113430 under ICR 198506-0938-013 · OMB 0938-0326.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0326 can be found here:

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Information Collection (IC) Details

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IC Title:	INFORMATION COLLECTION REQUIREMENTS IN 42 CFR PART 434, SUBPARTS A THRU E, MEDICAID CONTRACTS WITH HEALTH MAINTENANCE ORGANIZATIONS (HMOS) & PREPAID HEALTH PLANS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HCFA-R-27				No	No
Form	R-28				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	90	-606	696
Annual IC Time Burden (Hours)	42,070	-86,330	128,400
Annual IC Cost Burden (Dollars)	0	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.