Prepaid Health Plan Cost Report

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 276-99 Prepaid Health Plan Cost Report (HCPPS)	Form	Modified	Available
Form CMS-276 Prepaid Health Plan Cost Report (HMO)	Form	Modified	Available
CMS Formal Response to Comments Received_Cleanvj 508.pdf	Supplementary Document	Uploaded 2013-05-16	Available
Crosswalk for Revisions Final Cost Report 4-2013vj 508.pdf	Supplementary Document	Uploaded 2013-05-16	Available
Summary of Changes_2012 Cost Reports vj508.pdf	Supplementary Document	Uploaded 2013-05-16	Repair queued
Comments_to_CMS_on_Budget_and_Cost_report_proposed_changes_02_2013.pdf	Supplementary Document	Uploaded 2013-05-16	Available
Crosswalk for Revisions Budget 4-2013 vj508.pdf	Supplementary Document	Uploaded 2013-05-16	Available
CMS-276 Supporting Statement Part A 10-4-2012 vj 508.pdf.pdf	Supporting Statement A	Uploaded 2013-05-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43653	Prepaid Health Plan Cost Report (HCPPS)	Form	Modified
190488	Prepaid Health Plan Cost Report (HMO)	Form	Modified

ICR Details

OMB Control No: 0938-0165	ICR Reference No: 201305-0938-010
Status: Historical Active	Previous ICR Reference No: 200908-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: 19624
Title: Prepaid Health Plan Cost Report
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/06/2013
	Date Received in OIRA: 05/20/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2016	36 Months From Approved
Responses	106	0	0
Time Burden (Hours)	4,372	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: These forms are needed to establish the reasonable cost of providing covered services to the enrolled Medicare population of an HMO/CMP/HCPP in accordance with Sections 1876 and 1833 of the Social Security Act.

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Authorizing Statute(s): US Code: 42 USC 417 Name of Law: Health Maintenance Organizations, Competitive Medical Plans, and Health Care Prepayment Plans
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 6331	01/30/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 26034	05/03/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Prepaid Health Plan Cost Report (HCPPS)	276-99, CMS-276, CMS-276, CMS-276	Prepaid Health Plan Cost Report Worksheet ,   Final Cost Report ,   Budget Forecast ,   Inventory-Cost Report
Prepaid Health Plan Cost Report (HMO)	CMS-276, CMS-276, CMS-276, CMS-276	Final Cost Report ,   4th Quarter Cost Report ,   Interim Report ,   Budget Forecast

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	106	0	0	0	-22	128
Annual Time Burden (Hours)	4,372	0	0	0	-912	5,284
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The main purpose of the revisions was to implement some changes in response to the Affordable Care Act, which eliminated Part B coinsurance and deductibles for the majority of preventative services. Additional updates were made to eliminate redundant information and make improvements to the cost reports. Please note that this updated version can not reflect any of the anticipated/future policy changes until they have been finalized and implemented. While plans are required to report Part B services not subject to coinsurance and deductible separately, CMS believes that this information has to be tracked and available to plans to make proper payments. In addition, CMS removed certain reporting requirements and automated the flow of certain figures. Therefore, the proposed changes will not change the level of effort needed to complete the forms.

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Annual Cost to Federal Government: $192,608

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/20/2013

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