Alternative Benefits State Plan Amendment HOA Demonstration Program (CMS-10216)

Alternative Benefits State Plan Amendment Health Opportunity Accounts Demonstration Program (CMS-10216)

Documents and Forms

Document Name Document Type
SMD011007.pdf Instruction
CMS-10216 HOA Pre-print Final HOA_preprintfinal112906.pdf Form
US Code Title 26A1BVII.pdf US Code Title 26A1BVII IC Document
30-day FR.pdf 30-day FR notice IC Document
AARP May 22, 2007 comment.tif Comment IC Document
Response to Comment from AARP.doc Response to Comment from AARP IC Document
60-day FR.pdf 60-day FR IC Document

Information Collection (IC) Details

IC Title:	Alternative Benefits State Plan Amendment HOA Demonstration Program (CMS-10216)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Instruction			SMD011007.pdf		No	No	Paper Only
Form	CMS-10216	HOA Pre-print Final	HOA_preprintfinal112906.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
US Code Title 26A1BVII	US Code Title 26A1BVII.pdf	06/15/2007
30-day FR notice	30-day FR.pdf	06/15/2007
Comment	AARP May 22, 2007 comment.tif	06/15/2007
Response to Comment from AARP	Response to Comment from AARP.doc	06/15/2007
60-day FR	60-day FR.pdf	06/15/2007

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