Annual State Report and Annual State Performance Rankings (CMS-10241)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1041 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10241 Annual State Report and Annual State Performance Rankings (CMS-10241) Form and Instruction
CMS-10241 State Payment and Utilization Rates and Performance Rank CMS-10241-CMSStatesAnalysisdatacollectiontemplate v4.xls Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Annual State Report and Annual State Performance Rankings (CMS-10241)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10241	State Payment and Utilization Rates and Performance Rankings Data Collection Form	CMS-10241-CMSStatesAnalysisdatacollectiontemplate v4.xls		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	765	765
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.