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Medicare Advantage Applications - Part C
Medicare Advantage Applications - Part C
OMB: 0938-0935
IC ID: 8785
OMB.report
HHS/CMS
OMB 0938-0935
ICR 200801-0938-004
IC 8785
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0935 can be found here:
2024-11-19 - Revision of a currently approved collection
2022-10-13 - Revision of a currently approved collection
Documents and Forms
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
Information Collection (IC) Details
View Information Collection (IC)
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:
Document Type
Form No.
Form Name
Instrument File
URL
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
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:
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
241
0
21
0
0
220
Annual IC Time Burden (Hours)
5,858
0
278
0
0
5,580
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.