Information Collection

Medicare Advantage Applications

IC 8785 under ICR 200612-0938-009 · OMB 0938-0935.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0935 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10117 CCP Medicare Advantage Applications	Form and Instruction
CMS-10117 CCP Application Coordinated Care Plans PRACollection CMS10117-CCP.zip	Form and Instruction
CMS-10118 PFFS Application Provate Fee for Service Plans PRACollectionCMS10118-PFFS.zip	Form and Instruction
CMS-10119 RPPO Application Regional PPO Plans PRACollectionCMS10119-RPPO.zip	Form and Instruction
CMS-10135 SAE Application Service Area Expansion for Coordinated Care PRACollectionCMS10135-SAE.zip	Form and Instruction
CMS-10136 MSA Medical Savings Account Plans PRACollectionCMS10136-MSA..zip	Form and Instruction
CMS-10214 EGWP Employer Group Waiver Plans PRACollectionCMS10214-EGWP..zip	Form and Instruction
CMS-10117,10118,10 General Files and Guides PRACollection-generalfiles --CMS 10117,10118,10119,10135,10136,10214.zip	Form and Instruction
Revised Part C Justification for Emergency Edited 10062006 (Rev.10-17)).DOC Emergency Justification	IC Document
cert.doc Cert	IC Document
CLEAN - cert.doc Clean Cert	IC Document
CLEAN - DRAFT 2008 MA application Guidelines 1-18-07.DOC Clean Draft 2008 MA Application Guidelines	IC Document
CLEAN - HSD.XLS Clean HSD	IC Document
CLEAN - Legal-1.doc Clean Legal-1	IC Document
CLEAN - Legal-2.xls Clean Legal 2	IC Document
CLEAN - matrix1.doc Clean Matrix 1	IC Document
CLEAN - matrix2.doc Clean Matrix 2	IC Document
CLEAN - matrixadm.DOC Clea Matrix ADM	IC Document
CMS-10117. Draft 2008 CCP application 1-18-07.doc Draft 2008 CCP App	IC Document
CMS-10117-CLEAN Draft 2008 CCP application 1-18-07.doc Clean Draft 2008 CCP App	IC Document
CMS-10118.CLEAN Draft_2008_PFFS_Application-1-19-07 YR.doc Clean Draft 2008 PFFS App	IC Document
CMS-10118.CLEAN-State license.doc Clean State License	IC Document
CMS-10118.Draft_2008_PFFS_Application-1-19-07 YR.doc Draft 2008 PFFS App	IC Document
CMS-10118.license.doc License	IC Document
CMS-10119.CLEAN Draft 2008 RPPO Application 1-18-07.DOC Clean Draft RPPO App	IC Document
CMS-10119.CLEAN Essential Hospital Designation.doc Clean Essential Hospital Designation	IC Document
CMS-10119.Draft 2008 RPPO Application 1-18-07.DOC Draft RPPO App	IC Document
CMS-10119.essential.doc Essential	IC Document
CMS-10135.CLEAN DRAFT 2008 SAE Application 1-18-07-.DOC Clean Draft SAE App	IC Document
CMS-10135.DRAFT 2008 SAE Application 1-18-07-.DOC Draft SAE App	IC Document
CMS-10136.CLEAN DRAFT 2008 MSA Application 1-18-07.DOC Clean Draft MSA App	IC Document
CMS-10136.CLEAN DRAFT 2008 MSA Demo App 1-18-07.doc Clean Draft MSA Demo App	IC Document
CMS-10136.DRAFT 2008 MSA Application 1-18-07.DOC Draft MSA App	IC Document
CMS-10136.DRAFT 2008 MSA Demo App 1-18-07.doc Draft MSA Demo App	IC Document
CMS-10214.2008 EGWP MAO Application Redline.doc MAO App Redline	IC Document
CMS-10214.2008 EPOG Direct MA PFFS Application Redline.doc PFFS App Redline	IC Document
CMS-10214.CLEAN 2008 EGWP MAO Application.doc Clean MAO App	IC Document
CMS-10214.CLEAN 2008 EPOG Direct MA PFFS Application.doc Clean PFFS App	IC Document
DRAFT 2008 MA application Guidelines 1-18-07.DOC MA App Guidelines	IC Document
HSD.XLS HSD	IC Document
legal-1.doc Legal 1	IC Document
legal-2.xls Legal 2	IC Document
matrix1.doc Matrix 1	IC Document
matrix2.doc Matrix 2	IC Document
matrixadm.DOC Matrix ADM	IC Document
cert (final2008).doc Final 2008 MA CCP Application cert (final2008)	IC Document
HSD (final2008).xls Final 2008 MA CCP Application HSD (final2008)	IC Document
legal-1.(final2008).doc Final 2008 MA CCP Application legal-1 (final2008)	IC Document
legal-2 (final2008).xls Final 2008 MA CCP Application legal-2(final2008)	IC Document
matrix1(final2008).doc Final 2008 MA CCP Application matrix1(final2008)	IC Document
matrix2(final2008).doc Final 2008 MA CCP Application matrix2 (final2008)	IC Document
matrixadm (final2008).DOC Final 2008 MA CCP Application matrixadm (final2008).	IC Document
Final 2008 CCP application 1-07doc.doc Final 2008 MA CCP Application Final 2008 CCP application 1-07	IC Document
Final 2008 MA application Guidelines 1-07.DOC Final 2008 MA CCP Application Final 2008 MA application Guidelines 1-07	IC Document
cert (final2008).doc Final 2008 MA MSA Application cert (final2008)	IC Document
Final 2008 MA application Guidelines 1-07.DOC Final 2008 MA MSA Application Final 2008 MA application Guidelines 1-07	IC Document
FINAL 2008 MSA Demo App 1-07.doc Final 2008 MA MSA Application FINAL 2008 MSA Demo App 1-07	IC Document
Final 2008 MSA Application 1-07.DOC Final 2008 MA MSA Application Final 2008 MSA Application 1-07	IC Document
legal-1.(final2008).doc Final 2008 MA MSA Application legal-1 (final2008)	IC Document
matrixadm (final2008).DOC Final 2008 MA MSA Application matrixadm (final2008)	IC Document
cert (final2008).doc Final 2008 MA PFFS Application cert (final2008)	IC Document
Final 2008 MA application Guidelines 1-07.DOC Final 2008 MA PFFS Application Final 2008 MA application Guidelines 1-07	IC Document
Final 2008 MA PFFS Application-1-07.doc Final 2008 MA PFFS Application\Final 2008 MA PFFS Application-1-07	IC Document
HSD (final2008).xls Final 2008 MA PFFS Application\HSD (final2008).	IC Document
legal-1.(final2008).doc Final 2008 MA PFFS Application\legal-1.(final2008).	IC Document
legal-2 (final2008).xls Final 2008 MA PFFS Application\legal-2 (final2008)	IC Document
license (final2008).doc Final 2008 MA PFFS Application\license (final2008).	IC Document
matrix1(final2008).doc Final 2008 MA PFFS Application\matrix1(final2008)	IC Document
matrix2(final2008).doc Final 2008 MA PFFS Application\matrix2(final2008	IC Document
matrixadm (final2008).DOC Final 2008 MA PFFS Application\matrixadm (final2008)	IC Document
cert (final2008).doc Final 2008 RPPO Application\cert (final2008)	IC Document
essential (final2008).doc Final 2008 RPPO Application\essential (final2008)	IC Document
Final 2008 MA application Guidelines 1-07.DOC Final 2008 RPPO Application\Final 2008 MA application Guidelines 1-07	IC Document
FINAL 2008 RPPO Application 1-07.DOC Final 2008 RPPO Application\FINAL 2008 RPPO Application 1-07	IC Document
HSD (final2008).xls Final 2008 RPPO Application\HSD (final2008)	IC Document
legal-1.(final2008).doc Final 2008 RPPO Application\legal-1.(final2008	IC Document
legal-2 (final2008).xls Final 2008 RPPO Application\legal-2 (final2008)	IC Document
matrix1(final2008).doc Final 2008 RPPO Application\matrix1(final2008	IC Document
matrix2(final2008).doc Final 2008 RPPO Application\matrix2(final2008)	IC Document
matrixadm (final2008).DOC Final 2008 RPPO Application\matrixadm (final2008)	IC Document
cert (final2008).doc Final MA\cert (final2008)	IC Document
Final 2008 MA application Guidelines 1-07.DOC Final MA\Final 2008 MA application Guidelines 1-07	IC Document
Final 2008 SAE Application 1-07-.DOC Final MA\Final 2008 SAE Application 1-07	IC Document
HSD (final2008).xls Final MA\HSD (final2008)	IC Document
legal-1.(final2008).doc Final MA\legal-1.(final2008)	IC Document
legal-2 (final2008).xls Final MA\legal-2 (final2008).	IC Document
matrix1(final2008).doc Final MA\matrix1(final2008)	IC Document
matrix2(final2008).doc Final MA\matrix2(final2008)	IC Document
matrixadm (final2008).DOC Final MA\matrixadm (final2008)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medicare Advantage Applications

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 422.501

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10117 CCP	Application Coordinated Care Plans	PRACollection CMS10117-CCP.zip	Yes	Yes	Paper Only
Form and Instruction	CMS-10118 PFFS	Application Provate Fee for Service Plans	PRACollectionCMS10118-PFFS.zip	Yes	Yes	Paper Only
Form and Instruction	CMS-10119 RPPO	Application Regional PPO Plans	PRACollectionCMS10119-RPPO.zip	Yes	Yes	Paper Only
Form and Instruction	CMS-10135 SAE	Application Service Area Expansion for Coordinated Care Plans: Private Fee Service Plans	PRACollectionCMS10135-SAE.zip	Yes	Yes	Paper Only
Form and Instruction	CMS-10136 MSA	Medical Savings Account Plans	PRACollectionCMS10136-MSA..zip	Yes	Yes	Paper Only
Form and Instruction	CMS-10214 EGWP	Employer Group Waiver Plans	PRACollectionCMS10214-EGWP..zip	Yes	Yes	Paper Only
Form and Instruction	CMS-10117,10118,10119,10135,10136,10214	General Files and Guides	PRACollection-generalfiles --CMS 10117,10118,10119,10135,10136,10214.zip	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: 220

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: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	220	110	110
Annual IC Time Burden (Hours)	5,580	2,180	3,400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Emergency Justification	Revised Part C Justification for Emergency Edited 10062006 (Rev.10-17)).DOC	12/08/2006
Cert	cert.doc	01/19/2007
Clean Cert	CLEAN - cert.doc	01/19/2007
Clean Draft 2008 MA Application Guidelines	CLEAN - DRAFT 2008 MA application Guidelines 1-18-07.DOC	01/19/2007
Clean HSD	CLEAN - HSD.XLS	01/19/2007
Clean Legal-1	CLEAN - Legal-1.doc	01/19/2007
Clean Legal 2	CLEAN - Legal-2.xls	01/19/2007
Clean Matrix 1	CLEAN - matrix1.doc	01/19/2007
Clean Matrix 2	CLEAN - matrix2.doc	01/19/2007
Clea Matrix ADM	CLEAN - matrixadm.DOC	01/19/2007
Draft 2008 CCP App	CMS-10117. Draft 2008 CCP application 1-18-07.doc	01/19/2007
Clean Draft 2008 CCP App	CMS-10117-CLEAN Draft 2008 CCP application 1-18-07.doc	01/19/2007
Clean Draft 2008 PFFS App	CMS-10118.CLEAN Draft_2008_PFFS_Application-1-19-07 YR.doc	01/19/2007
Clean State License	CMS-10118.CLEAN-State license.doc	01/19/2007
Draft 2008 PFFS App	CMS-10118.Draft_2008_PFFS_Application-1-19-07 YR.doc	01/19/2007
License	CMS-10118.license.doc	01/19/2007
Clean Draft RPPO App	CMS-10119.CLEAN Draft 2008 RPPO Application 1-18-07.DOC	01/19/2007
Clean Essential Hospital Designation	CMS-10119.CLEAN Essential Hospital Designation.doc	01/19/2007
Draft RPPO App	CMS-10119.Draft 2008 RPPO Application 1-18-07.DOC	01/19/2007
Essential	CMS-10119.essential.doc	01/19/2007
Clean Draft SAE App	CMS-10135.CLEAN DRAFT 2008 SAE Application 1-18-07-.DOC	01/19/2007
Draft SAE App	CMS-10135.DRAFT 2008 SAE Application 1-18-07-.DOC	01/19/2007
Clean Draft MSA App	CMS-10136.CLEAN DRAFT 2008 MSA Application 1-18-07.DOC	01/19/2007
Clean Draft MSA Demo App	CMS-10136.CLEAN DRAFT 2008 MSA Demo App 1-18-07.doc	01/19/2007
Draft MSA App	CMS-10136.DRAFT 2008 MSA Application 1-18-07.DOC	01/19/2007
Draft MSA Demo App	CMS-10136.DRAFT 2008 MSA Demo App 1-18-07.doc	01/19/2007
MAO App Redline	CMS-10214.2008 EGWP MAO Application Redline.doc	01/19/2007
PFFS App Redline	CMS-10214.2008 EPOG Direct MA PFFS Application Redline.doc	01/19/2007
Clean MAO App	CMS-10214.CLEAN 2008 EGWP MAO Application.doc	01/19/2007
Clean PFFS App	CMS-10214.CLEAN 2008 EPOG Direct MA PFFS Application.doc	01/19/2007
MA App Guidelines	DRAFT 2008 MA application Guidelines 1-18-07.DOC	01/19/2007
HSD	HSD.XLS	01/19/2007
Legal 1	legal-1.doc	01/19/2007
Legal 2	legal-2.xls	01/19/2007
Matrix 1	matrix1.doc	01/19/2007
Matrix 2	matrix2.doc	01/19/2007
Matrix ADM	matrixadm.DOC	01/19/2007
Final 2008 MA CCP Application cert (final2008)	cert (final2008).doc	01/31/2007
Final 2008 MA CCP Application HSD (final2008)	HSD (final2008).xls	01/31/2007
Final 2008 MA CCP Application legal-1 (final2008)	legal-1.(final2008).doc	01/31/2007
Final 2008 MA CCP Application legal-2(final2008)	legal-2 (final2008).xls	01/31/2007
Final 2008 MA CCP Application matrix1(final2008)	matrix1(final2008).doc	01/31/2007
Final 2008 MA CCP Application matrix2 (final2008)	matrix2(final2008).doc	01/31/2007
Final 2008 MA CCP Application matrixadm (final2008).	matrixadm (final2008).DOC	01/31/2007
Final 2008 MA CCP Application Final 2008 CCP application 1-07	Final 2008 CCP application 1-07doc.doc	01/31/2007
Final 2008 MA CCP Application Final 2008 MA application Guidelines 1-07	Final 2008 MA application Guidelines 1-07.DOC	01/31/2007
Final 2008 MA MSA Application cert (final2008)	cert (final2008).doc	01/31/2007
Final 2008 MA MSA Application Final 2008 MA application Guidelines 1-07	Final 2008 MA application Guidelines 1-07.DOC	01/31/2007
Final 2008 MA MSA Application FINAL 2008 MSA Demo App 1-07	FINAL 2008 MSA Demo App 1-07.doc	01/31/2007
Final 2008 MA MSA Application Final 2008 MSA Application 1-07	Final 2008 MSA Application 1-07.DOC	01/31/2007
Final 2008 MA MSA Application legal-1 (final2008)	legal-1.(final2008).doc	01/31/2007
Final 2008 MA MSA Application matrixadm (final2008)	matrixadm (final2008).DOC	01/31/2007
Final 2008 MA PFFS Application cert (final2008)	cert (final2008).doc	01/31/2007
Final 2008 MA PFFS Application Final 2008 MA application Guidelines 1-07	Final 2008 MA application Guidelines 1-07.DOC	01/31/2007
Final 2008 MA PFFS Application\Final 2008 MA PFFS Application-1-07	Final 2008 MA PFFS Application-1-07.doc	01/31/2007
Final 2008 MA PFFS Application\HSD (final2008).	HSD (final2008).xls	01/31/2007
Final 2008 MA PFFS Application\legal-1.(final2008).	legal-1.(final2008).doc	01/31/2007
Final 2008 MA PFFS Application\legal-2 (final2008)	legal-2 (final2008).xls	01/31/2007
Final 2008 MA PFFS Application\license (final2008).	license (final2008).doc	01/31/2007
Final 2008 MA PFFS Application\matrix1(final2008)	matrix1(final2008).doc	01/31/2007
Final 2008 MA PFFS Application\matrix2(final2008	matrix2(final2008).doc	01/31/2007
Final 2008 MA PFFS Application\matrixadm (final2008)	matrixadm (final2008).DOC	01/31/2007
Final 2008 RPPO Application\cert (final2008)	cert (final2008).doc	01/31/2007
Final 2008 RPPO Application\essential (final2008)	essential (final2008).doc	01/31/2007
Final 2008 RPPO Application\Final 2008 MA application Guidelines 1-07	Final 2008 MA application Guidelines 1-07.DOC	01/31/2007
Final 2008 RPPO Application\FINAL 2008 RPPO Application 1-07	FINAL 2008 RPPO Application 1-07.DOC	01/31/2007
Final 2008 RPPO Application\HSD (final2008)	HSD (final2008).xls	01/31/2007
Final 2008 RPPO Application\legal-1.(final2008	legal-1.(final2008).doc	01/31/2007
Final 2008 RPPO Application\legal-2 (final2008)	legal-2 (final2008).xls	01/31/2007
Final 2008 RPPO Application\matrix1(final2008	matrix1(final2008).doc	01/31/2007
Final 2008 RPPO Application\matrix2(final2008)	matrix2(final2008).doc	01/31/2007
Final 2008 RPPO Application\matrixadm (final2008)	matrixadm (final2008).DOC	01/31/2007
Final MA\cert (final2008)	cert (final2008).doc	01/31/2007
Final MA\Final 2008 MA application Guidelines 1-07	Final 2008 MA application Guidelines 1-07.DOC	01/31/2007
Final MA\Final 2008 SAE Application 1-07	Final 2008 SAE Application 1-07-.DOC	01/31/2007
Final MA\HSD (final2008)	HSD (final2008).xls	01/31/2007
Final MA\legal-1.(final2008)	legal-1.(final2008).doc	01/31/2007
Final MA\legal-2 (final2008).	legal-2 (final2008).xls	01/31/2007
Final MA\matrix1(final2008)	matrix1(final2008).doc	01/31/2007
Final MA\matrix2(final2008)	matrix2(final2008).doc	01/31/2007
Final MA\matrixadm (final2008)	matrixadm (final2008).DOC	01/31/2007

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