Information Collection

Information Collection #18: Alternative Benefit Plans

IC 207634 under ICR 201111-0938-009 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10398 (#18) Information Collection #18: Alternative Benefit Plans Form
CMS-10398 (#18) Mock-up of Interim Form for Alternative Benefit Plans ABP MockUp_Final_7_2_13 [rev 7-3-2013 by OSORA PRA].docx Form
Alternative Benefit Plans Supporting Statement [rev 7-3-2013 by OSORA PRA].docx Supporting Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Information Collection #18: Alternative Benefit Plans	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 (#18)	Mock-up of Interim Form for Alternative Benefit Plans	ABP MockUp_Final_7_2_13 [rev 7-3-2013 by OSORA PRA].docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	56	0	0	0	0	0
Annual IC Time Burden (Hours)	448	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	Alternative Benefit Plans Supporting Statement [rev 7-3-2013 by OSORA PRA].docx	07/03/2013

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