Competitive Medical Plan, Medicare Contract Application, Medicare Contract Application for Federally Qualified HMO and Supporting Regulations -- 42 CFR 417.408, 417.143

ICR 199709-0938-001

OMB: 0938-0470

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0470 199709-0938-001
Historical Active 199407-0938-006
HHS/CMS
Competitive Medical Plan, Medicare Contract Application, Medicare Contract Application for Federally Qualified HMO and Supporting Regulations -- 42 CFR 417.408, 417.143
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 10/31/1997
Retrieve Notice of Action (NOA) 09/03/1997
  Inventory as of this Action Requested Previously Approved
11/30/2000 11/30/2000
65 0 0
6,500 0 0
0 0 0

Prepaid health plans must meet cerain regulatory requirements to be a federally qualified health maintenance organization that is eligible for a Medicare 1876 contract or a competitive medical plan with a Medicare 1876 contract. The applications are the collection forms to obtain the information from a health plan that would allow HCFA staff to determine compliance with the regulations.

None
None


No

1
IC Title Form No. Form Name
Competitive Medical Plan, Medicare Contract Application, Medicare Contract Application for Federally Qualified HMO and Supporting Regulations -- 42 CFR 417.408, 417.143 HCFA-901-1, HCFA-901-2, HCFA-901-3

  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 65 0 0 65 0 0
Annual Time Burden (Hours) 6,500 0 0 6,500 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
09/03/1997


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