Information Collection

Methodology to Identify Rate Differential (FFP for Managed Care Payments) in sec. 438.804(a)(2) and (a)(3)

IC 202304 under ICR 201205-0938-003 · OMB 0938-1170.

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Information Collection (IC) Details

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IC Title:	Methodology to Identify Rate Differential (FFP for Managed Care Payments) in sec. 438.804(a)(2) and (a)(3)	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 438.804(a)(3)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	504	504
Annual IC Cost Burden (Dollars)	0	0

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