Prepaid Health Plan Cost Report

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-276 CMS-276.Interim report	Form	Modified	Available
Form CMS-276 CMS-276.Final Cost Report	Form	Modified	Available
Form CMS-276 CMS-276.Budget Forecast	Form	Modified	Available
Form CMS-276 CMS-276.4th Quarter Report	Form	Modified	Available
Form CMS-276 Budget Forecast	Form	New	Available
Form CMS-276 4th Quarter Cost Report	Form	New	Available
Form CMS-276 Final Cost Report	Form	New	Repair queued
Form CMS-276 Interim Report	Form	New	Available
CMS-276.Crosswalk for Revisions to Final Cost report & 4th Qtr.doc	Supplementary Document	Uploaded 2009-08-17	Available
CMS-276.Crosswalk for Revisions to Budget Forecast.doc	Supplementary Document	Uploaded 2009-08-17	Available
CMS-276.Supporting Statement Part A.doc	Supporting Statement A	Uploaded 2009-08-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43653	Prepaid Health Plan Cost Report (HCPPS)	Form	Modified	CMS-276.Interim report
43653	Prepaid Health Plan Cost Report (HCPPS)	Form	Modified	CMS-276.Final Cost Report
43653	Prepaid Health Plan Cost Report (HCPPS)	Form	Modified	CMS-276.Budget Forecast
43653	Prepaid Health Plan Cost Report (HCPPS)	Form	Modified	CMS-276.4th Quarter Report
43653	Prepaid Health Plan Cost Report (HCPPS)	Instruction	Modified
190488	Prepaid Health Plan Cost Report (HMO)	Form	New	Budget Forecast
190488	Prepaid Health Plan Cost Report (HMO)	Form	New	4th Quarter Cost Report
190488	Prepaid Health Plan Cost Report (HMO)	Form	New	Final Cost Report
190488	Prepaid Health Plan Cost Report (HMO)	Form	New	Interim Report
190488	Prepaid Health Plan Cost Report (HMO)	Instruction	New

ICR Details

OMB Control No: 0938-0165	ICR Reference No: 200908-0938-012
Status: Historical Active	Previous ICR Reference No: 200605-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Prepaid Health Plan Cost Report
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/26/2009
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/31/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2012	36 Months From Approved	10/31/2009
Responses	128	0	225
Time Burden (Hours)	5,284	0	7,860
Cost Burden (Dollars)	0	0	0

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Abstract: These forms are needed to establish the reasonable cost of providing covered services to the enrolled Medicare population of an HMO/CMP/HCPP in accordance with Sections 1876 and 1833 of the Social Security Act.

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Authorizing Statute(s): US Code: 42 USC 417 Name of Law: Health Maintenance Organizations, Competitive Medical Plans, and Health Care Prepayment Plans
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 22932	05/15/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 41141	08/14/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Prepaid Health Plan Cost Report (HCPPS)	CMS-276, CMS-276, CMS-276, CMS-276	CMS-276.4th Quarter Report ,   CMS-276.Budget Forecast ,   CMS-276.Final Cost Report ,   CMS-276.Interim report
Prepaid Health Plan Cost Report (HMO)	CMS-276, CMS-276, CMS-276, CMS-276	Interim Report ,   Final Cost Report ,   4th Quarter Cost Report ,   Budget Forecast

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	128	225	0	0	-97	0
Annual Time Burden (Hours)	5,284	7,860	0	0	-2,576	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $192,608

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/28/2009

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