Information Collection

Medicare Advantage Applications - Part C

IC 8785 under ICR 200801-0938-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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
2009 Direct Contract MAO Application redline.doc	Other-redline
2009 EGWP MAO Application_redline.doc	Other-redline
2009 Final Part C Application 1-10-2008 Redline.doc	Other-Redline CMS-10237
CMS-10214 Medicare Advantage Prescription Drug Benefit 12-27-07 2009 EGWP MAO Application_Final.doc	Form and Instruction
CMS-10214 2009 Initial App for Employer/Union Direct Contract PFFS 12-27-07 2009 Direct Contract MAO Application_FINAL.doc	Form and Instruction
CMS-10237 Medicare Advantage Master Application Clean-2009 Final Part C Application 1-10-2008 .doc	Form and Instruction
12-27-07 EPOG MAO Applications_High level summary of changes_Final.doc 12-27-07 EPOG MAO Applications_High level summary of changes_Final	IC Document
Highlevel-SummaryChanges 2008 to 2009 Part C applications.doc Highlevel-SummaryChanges 2008 to 2009 Part C applications	IC Document

IC Title:

Medicare Advantage Applications - Part C

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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
Other-redline			2009 Direct Contract MAO Application redline.doc	Yes	Yes	Paper Only
Other-redline			2009 EGWP MAO Application_redline.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10214	Medicare Advantage Prescription Drug Benefit	12-27-07 2009 EGWP MAO Application_Final.doc	Yes	Yes	Paper Only
Other-Redline CMS-10237			2009 Final Part C Application 1-10-2008 Redline.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10214	2009 Initial App for Employer/Union Direct Contract PFFS MA Organization	12-27-07 2009 Direct Contract MAO Application_FINAL.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10237	Medicare Advantage Master Application	Clean-2009 Final Part C Application 1-10-2008 .doc	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 241

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	241	21	220
Annual IC Time Burden (Hours)	5,858	278	5,580
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
12-27-07 EPOG MAO Applications_High level summary of changes_Final	12-27-07 EPOG MAO Applications_High level summary of changes_Final.doc	12/27/2007
Highlevel-SummaryChanges 2008 to 2009 Part C applications	Highlevel-SummaryChanges 2008 to 2009 Part C applications.doc	01/11/2008

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