Information Collection

Prepaid Health Plan Cost Report (HMO)

IC 190488 under ICR 201305-0938-010 · OMB 0938-0165.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0165 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-276 Prepaid Health Plan Cost Report (HMO)	Form
CostReportInstructionsFinal vj 508.pdf	Instruction
CMS-276 4th Quarter Cost Report CMS-276.4th Quarter Report.xls	Form
CMS-276 Interim Report interim(1) vj508.pdf	Form
CMS-276 Final Cost Report FinalCostReport-Revised vj508.pdf	Form
CMS-276 Budget Forecast Budget-Revised vj508.pdf	Form

IC Title:

Prepaid Health Plan Cost Report (HMO)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 417.572 42 CFR 417.576

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	CMS-276	Final Cost Report	FinalCostReport-Revised vj508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-276	4th Quarter Cost Report	CMS-276.4th Quarter Report.xls	Yes	Yes	Fillable Fileable
Instruction			CostReportInstructionsFinal vj 508.pdf	Yes	No	Fillable Printable
Form	CMS-276	Interim Report	interim(1) vj508.pdf	Yes	Yes	Fillable Printable
Form	CMS-276	Budget Forecast	Budget-Revised vj508.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 19

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 85 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	76	-16	92
Annual IC Time Burden (Hours)	3,572	-752	4,324
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.