Prepaid Health Plan Cost Report (HMO)

Prepaid Health Plan Cost Report

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.