Information Collection

Medicare Advantage Applications - Part C

IC 8785 under ICR 200809-0938-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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
CMS-10237 2010DraftApplication-9208finalredlinever 3.doc	Other-redline
CMS-10214 2009 Direct Contract MAO Applicationredline.docm	Other-redline
CMS-10214 2009 EGWP MAO Application_Finalbb.doc	Other-redline
High level Summ_2010_Application_Revisions_12-05-2008.doc	Other-5
CMS-10214 2009 EGWP MAO Applicationfinal1125(cleanversion).doc	Other-a
CMS-10214 2009 EGWP MAO Applicationredline1125(3).doc	Other-b
CMS10237-PartC-MA-APP-CLEANVERSION-12-4-08.doc	Other-b
CMS10237-PartC-MA-APP- Redlineversion- 12-4-08(aftercomments).doc	Other-c
Combined HSD 12-04-2008.xls	Other-d
CMS-10237 PART C -MEDICARE ADVANTAGE CMS-10237 2010DraftApplication-9308finalclean 3.doc	Form and Instruction
CMS-10214 2010 INITIAL APPLICATION FOR Employer/Union Direct Contr CMS-10214 2009 Direct Contract MAO Applicationfinal.docm	Form and Instruction
CMS-10214 2010 Application Instructions for MA Organizations to Of CMS-10214 2009 EGWP MAO Application_Final _part c cleanbb1.doc	Form and Instruction
CMS Admin-Management-Contract Matrix.DOC CMS Admin-Management-Contract Matrix	IC Document
HFLC_CMS State Certification_082208 (comments).doc HFLC_CMS State Certification_082208 (comments)	IC Document
High level Summ_2010_Application_Revisions_090308.doc High level Summ_2010_Application_Revisions_090308	IC Document
LC-DraftAdminContract Matrix8-13-08clean (3).doc LC-DraftAdminContract Matrix8-13-08clean (3)	IC Document
LC-DraftRevisedProvider Contract Matrix9208final (2).doc LC-DraftRevisedProvider Contract Matrix9208final (2)	IC Document
Revised HSD 1MARKUP.XLS Revised HSD 1MARKUP	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 422.524 42 CFR 422.527 42 CFR 422.502 42 CFR 422.505 42 CFR 422.514 42 CFR 422.520 42 CFR 422.501 42 CFR 422.503 42 CFR 422.504 42 CFR 422.506 42 CFR 422.508 42 CFR 422.510 42 CFR 422.512 42 CFR 422.516 42 CFR 422.500 42 CFR 422.521

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			CMS-10237 2010DraftApplication-9208finalredlinever 3.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10214	2010 INITIAL APPLICATION FOR Employer/Union Direct Contract PFFS MAO	CMS-10214 2009 Direct Contract MAO Applicationfinal.docm	Yes	Yes	Paper Only
Other-redline			CMS-10214 2009 Direct Contract MAO Applicationredline.docm	Yes	Yes	Paper Only
Form and Instruction	CMS-10214	2010 Application Instructions for MA Organizations to Offer New Employer/Union-Only Group Waiver Plans (EGWPs)	CMS-10214 2009 EGWP MAO Application_Final _part c cleanbb1.doc	Yes	Yes	Paper Only
Other-redline			CMS-10214 2009 EGWP MAO Application_Finalbb.doc	Yes	Yes	Paper Only
Form and Instruction	CMS-10237	PART C -MEDICARE ADVANTAGE	CMS-10237 2010DraftApplication-9308finalclean 3.doc	Yes	Yes	Paper Only
Other-c			CMS10237-PartC-MA-APP- Redlineversion- 12-4-08(aftercomments).doc	Yes	Yes	Paper Only
Other-5			High level Summ_2010_Application_Revisions_12-05-2008.doc	Yes	Yes	Paper Only
Other-a			CMS-10214 2009 EGWP MAO Applicationfinal1125(cleanversion).doc	Yes	Yes	Paper Only
Other-b			CMS-10214 2009 EGWP MAO Applicationredline1125(3).doc	Yes	Yes	Paper Only
Other-d			Combined HSD 12-04-2008.xls	Yes	Yes	Paper Only
Other-b			CMS10237-PartC-MA-APP-CLEANVERSION-12-4-08.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: 267

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 New Statute	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	267	10	16	241
Annual IC Time Burden (Hours)	6,490	222	410	5,858
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS Admin-Management-Contract Matrix	CMS Admin-Management-Contract Matrix.DOC	09/08/2008
HFLC_CMS State Certification_082208 (comments)	HFLC_CMS State Certification_082208 (comments).doc	09/08/2008
High level Summ_2010_Application_Revisions_090308	High level Summ_2010_Application_Revisions_090308.doc	09/08/2008
LC-DraftAdminContract Matrix8-13-08clean (3)	LC-DraftAdminContract Matrix8-13-08clean (3).doc	09/08/2008
LC-DraftRevisedProvider Contract Matrix9208final (2)	LC-DraftRevisedProvider Contract Matrix9208final (2).doc	09/08/2008
Revised HSD 1MARKUP	Revised HSD 1MARKUP.XLS	09/08/2008

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