Information Collection

Medicare Advantage Quality Bonus Payment Demonstration MAO mail survey

IC 206030 under ICR 201303-0938-002 · OMB 0938-1195.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10445 Medicare Advantage Quality Bonus Payment Demonstration MAO mail survey	Form and Instruction
CMS-10445 Initial Call Form Appendix C_Initial Call Form.docx	Form and Instruction
CMS-10445 Reminder Call Script Appendix D_Reminder Call Script.docx	Form and Instruction
CMS-10445 QBP MAO Survey QBP MAO Survey_02.01.2013_508.docx	Form and Instruction
Appendix E_FAQ.docx FAQ	IC Document
Appendix B_Letters to health plans.docx Letters to health plans	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10445	Initial Call Form	Appendix C_Initial Call Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10445	Reminder Call Script	Appendix D_Reminder Call Script.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10445	QBP MAO Survey	QBP MAO Survey_02.01.2013_508.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 620

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	620	620
Annual IC Time Burden (Hours)	610	610
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
FAQ	Appendix E_FAQ.docx	02/25/2013
Letters to health plans	Appendix B_Letters to health plans.docx	02/25/2013

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