Prepaid Health Plan Cost Report (HMO)

Prepaid Health Plan Cost Report

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0165 can be found here:

Documents and Forms

Document Name Document Type
CMS-276.Cost Report Instructions .pdf Instruction
CMS-276 Interim Report CMS-276.Interim Report.pdf Form
CMS-276 Final Cost Report CMS-276.Final Cost Report.xls Form
CMS-276 4th Quarter Cost Report CMS-276.4th Quarter Report.xls Form
CMS-276 Budget Forecast CMS-276.Budget Forecast.pdf Form

Information Collection (IC) Details

IC Title:	Prepaid Health Plan Cost Report (HMO)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 417.572 42 CFR 417.576

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-276.Cost Report Instructions .pdf	Yes	Yes	Fillable Fileable
Form	CMS-276	Interim Report	CMS-276.Interim Report.pdf	Yes	Yes	Fillable Fileable
Form	CMS-276	Final Cost Report	CMS-276.Final Cost Report.xls	Yes	Yes	Fillable Fileable
Form	CMS-276	4th Quarter Cost Report	CMS-276.4th Quarter Report.xls	Yes	Yes	Fillable Fileable
Form	CMS-276	Budget Forecast	CMS-276.Budget Forecast.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 23	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 85 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	92	92
Annual IC Time Burden (Hours)	4,324	4,324
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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