Medicare Advantage Applications

Medicare Advantage Applications - Part C

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
FINAL 2008_1_12_07 EGWP MAO_InstructionsOnly.doc Instruction
CMS-10214 EPOG FINAL 2007.1.11_2008_DirectMAPFFSApplication.DOC Form
CMS-10117 CCP Final 2008 MA CCP Application.zip Form and Instruction
CMS-10136 MSA Final 2008 MA MSA Application.zip Form and Instruction
CMS-10118 PFFS Final 2008 MA PFFS Application.zip Form and Instruction
CMS-10119 RPPO Final 2008 MA RPPO Application.zip Form and Instruction
CMS-10135 SAE Final 2008 MA SAE(CCP, PFFS, MSA) APPLICATION.zip Form and Instruction
MEDICARE ADVANTAGE GUIDELINES.doc MEDICARE ADVANTAGE GUIDELINES IC Document

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			FINAL 2008_1_12_07 EGWP MAO_InstructionsOnly.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10117	CCP	Final 2008 MA CCP Application.zip	Yes	Yes	Paper Only
Form and Instruction	CMS-10136	MSA	Final 2008 MA MSA Application.zip	Yes	Yes	Paper Only
Form and Instruction	CMS-10118	PFFS	Final 2008 MA PFFS Application.zip	Yes	Yes	Paper Only
Form and Instruction	CMS-10119	RPPO	Final 2008 MA RPPO Application.zip	Yes	Yes	Paper Only
Form and Instruction	CMS-10135	SAE	Final 2008 MA SAE(CCP, PFFS, MSA) APPLICATION.zip	Yes	Yes	Paper Only
Form	CMS-10214	EPOG	FINAL 2007.1.11_2008_DirectMAPFFSApplication.DOC	Yes	Yes	Paper Only

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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	220	220
Annual IC Time Burden (Hours)	5,580	5,580
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
MEDICARE ADVANTAGE GUIDELINES	MEDICARE ADVANTAGE GUIDELINES.doc	06/15/2007

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