Information Collection

Part C Medicare Advantage Application and 1876 Cost Plan Expansion Application

IC 8785 under ICR 201310-0938-014 · OMB 0938-0935.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0935 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Step 1 - Disclosure Statement (30day) clean.doc	Other-PRA Disclosure Statement
CY 2015 HSD Instructions (Rev 2 30day) CLEAN.pdf	Instruction
CMS-10237 Part C - Medicare Advantage and 1876 Cost Plan Expansion CY2015 Part C MA Application (rev 30 day) CLEAN 10-21-2013.pdf	Form and Instruction
CMS-10237 CY 2015 Medicare Advantage HSD Exception Request Templat CY2015 HSD Exception Request Template (30day) CLEAN.pdf	Form and Instruction
CMS-10237 2015 CMS MA Provider HSD Table CY 2015 CMS MA Provider HSD Table (30day) CLEAN.pdf	Form
CMS-10237 CY 2015 MA Facility HSD Table CY 2015 CMS MA Facility HSD Table (30day) CLEAN.pdf	Form
2015 High Levels Summary of Changes (30day) CLEAN 10-30-13.pdf Crosswalk	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Part C Medicare Advantage Application and 1876 Cost Plan Expansion Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.503 42 CFR 422.501 42 CFR 422.504 42 CFR 422.506 42 CFR 422.508 42 CFR 422.510 42 CFR 422.512 42 CFR 422.516 42 CFR 422.500 42 CFR 422.502 42 CFR 422.505 42 CFR 422.514 42 CFR 422.520 42 CFR 422.521 42 CFR 422.524 42 CFR 422.527 42 CFR 417.400

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
Other-PRA Disclosure Statement			Step 1 - Disclosure Statement (30day) clean.doc	Yes	No	Printable Only
Form and Instruction	CMS-10237	Part C - Medicare Advantage and 1876 Cost Plan Expansion Application	CY2015 Part C MA Application (rev 30 day) CLEAN 10-21-2013.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10237	CY 2015 Medicare Advantage HSD Exception Request Template	CY2015 HSD Exception Request Template (30day) CLEAN.pdf	Yes	Yes	Fillable Printable
Instruction			CY 2015 HSD Instructions (Rev 2 30day) CLEAN.pdf	Yes	No	Printable Only
Form	CMS-10237	2015 CMS MA Provider HSD Table	CY 2015 CMS MA Provider HSD Table (30day) CLEAN.pdf	Yes	Yes	Fillable Printable
Form	CMS-10237	CY 2015 MA Facility HSD Table	CY 2015 CMS MA Facility HSD Table (30day) CLEAN.pdf	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 566

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	566	0	566
Annual IC Time Burden (Hours)	22,955	1,374	21,581
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	2015 High Levels Summary of Changes (30day) CLEAN 10-30-13.pdf	10/31/2013

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