Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)

Medicare Advantage Application - Part C and 1876 Cost Plan Expansion Application regulations under 42 CFR 422 subpart K & 417.400

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0935 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10237 Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012) Form and Instruction
CMS-10237 Medicare Advantage Application - Part C and 1876 Cost Pl 2012 Part C MA and Cost Plan Application Clean August_2010.pdf Form and Instruction
CMS MA Additional and Supplment Benefits Table (2012 Draft).xls CMS MA Additional and Supplment Benefits Table (2012 Draft) IC Document
CMS MA Contract and Signature Index-Facilities (2012 Draft).xls CMS MA Contract and Signature Index-Facilities (2012 Draft) IC Document
2012 Draft HSD Instructions Clean (PRA-30daynotice).doc 2012 Draft HSD Instructions Clean (PRA-30daynotice) IC Document
CMS MA Facility Table (2012 Draft).xls CMS MA Facility Table (2012 Draft) IC Document
CMS MA Provider Table (2012 Draft).xls CMS MA Provider Table (2012 Draft) IC Document
CMS MA Signature Authority Grid (2012 Draft).xls CMS MA Signature Authority Grid (2012 Draft) IC Document

Information Collection (IC) Details

IC Title:	Part C Medicare Advantage Applications and 1876 Cost Plan Expansion Application (CY 2012)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 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 422.502 42 CFR 422.505 42 CFR 422.514 42 CFR 422.520 42 CFR 422.521 42 CFR 422.524 42 CFR 422.527 42 CFR 417.400

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10237	Medicare Advantage Application - Part C and 1876 Cost Plan Expansion Application	2012 Part C MA and Cost Plan Application Clean August_2010.pdf		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 870	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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	870	579	291
Annual IC Time Burden (Hours)	15,696	6,149	9,547
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS MA Additional and Supplment Benefits Table (2012 Draft)	CMS MA Additional and Supplment Benefits Table (2012 Draft).xls	09/17/2010
CMS MA Contract and Signature Index-Facilities (2012 Draft)	CMS MA Contract and Signature Index-Facilities (2012 Draft).xls	09/17/2010
2012 Draft HSD Instructions Clean (PRA-30daynotice)	2012 Draft HSD Instructions Clean (PRA-30daynotice).doc	09/17/2010
CMS MA Facility Table (2012 Draft)	CMS MA Facility Table (2012 Draft).xls	09/17/2010
CMS MA Provider Table (2012 Draft)	CMS MA Provider Table (2012 Draft).xls	09/17/2010
CMS MA Signature Authority Grid (2012 Draft)	CMS MA Signature Authority Grid (2012 Draft).xls	09/17/2010

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