CMS Application for Federal Qualification (901A); CMS Medicare Agreement Application (901D) and Supporting Regulations in 42 CFR Section 417.143 and 422.6

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS--901A Application for Federal Qualification (901A); Medicare Agreement Application (901D). Regulations in 42 CFR Section 417.143 and 422.6.	Form and Instruction	Modified	Available
CMS-901A&D sst-year2007 01092007.doc	Supporting Statement A	Uploaded 0000-00-00	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8097	Application for Federal Qualification (901A); Medicare Agreement Application (901D). Regulations in 42 CFR Section 417.143 and 422.6.	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0470	ICR Reference No: 200704-0938-001
Status: Historical Active	Previous ICR Reference No: 200311-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: CMS Application for Federal Qualification (901A); CMS Medicare Agreement Application (901D) and Supporting Regulations in 42 CFR Section 417.143 and 422.6
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/23/2007
	Date Received in OIRA: 04/15/2007
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2010	36 Months From Approved	08/31/2007
Responses	55	0	55
Time Burden (Hours)	2,200	0	5,958
Cost Burden (Dollars)	0	0	0

---

Abstract: Prepaid health plans must meet certain regulatory requirements to be federally qualified health maintenance organizations or to enter into a contract with CMS to provide health benefits to Medicare beneficiaries. The application is the collection form used to obtain information from a health plan; that will allow CMS staff to determine compliance with regulations.

---

Authorizing Statute(s): PL: Pub.L. 108 - 93 222 Name of Law: Health Maintenance of 1973
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 3852	01/26/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 17169	04/06/2007
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Application for Federal Qualification (901A); Medicare Agreement Application (901D). Regulations in 42 CFR Section 417.143 and 422.6.	CMS-901D, CMS--901A	Application For Federal Qualification ,   Medicare Agreement Application Health Care Prepayment Plan

---

ICR Summary of Burden

table that charts list of burden

	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	55	55	0	0	0	0
Annual Time Burden (Hours)	2,200	5,958	0	-3,758	0	0
Annual Cost Burden (Dollars)	0	0	0	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: We are requesting regular OMB approval extension of collection requirement contained in 42 CFR Section 417.143 and 422.6, Medicare Advantage Program. The collection documents are application forms, CMS-901 A and CMS 901-D; the user will be either a new applicant or a currently qualified HMO or contracting health plan requesting an expansion of its service area. Application titled Qualification Application Initial and Service Area Expansion CMS 901-A & Medicare Agreement Application Health Care Prepayment Plan CMS 901-D was approved under OMB number 0938-0470. Additionally, Applications 901-B and 901-C approved under OMB number 0938-0470 are being removed from this collection, due to their inclusion in OMB collection 0938-0935.

---

Annual Cost to Federal Government: $46,770

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 04/15/2007

---