Information Collection

Part C Medicare Advantage Application and 1876 Cost Plan Expansion Application

IC 8785 under ICR 201410-0938-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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.pdf	Other-PRA Disclosure Statement
CY2016 HSD Instructions (30day) clean.pdf	Instruction
CMS-10237 Part C - Medicare Advantage and 1876 Cost Plan Expansion CY2016 Part C - MA and 1876 Cost Plan Expansion Application 30dayclean.docx	Form and Instruction
CMS-10237 CY 2016 Medicare Advantage HSD Exception Request Templat CY2016 HSD Exception Request Template (30day) clean.pdf	Form
CMS-10237 Medicare Advantage Facility HSD Table CY2016 CMS MA Facility HSD Table (30day) clean.pdf	Form
CMS-10237 Medicare Advantage Provider HSD Table CY2016 CMS MA Provider HSD Table (30day) clean.pdf	Form
2016 High Levels Summary of Changes or Crosswalk of Changes (60day).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 417.400 42 CFR 422.501 42 CFR 422.503 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

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.pdf	No		Printable Only
Form and Instruction	CMS-10237	Part C - Medicare Advantage and 1876 Cost Plan Expansion Application	CY2016 Part C - MA and 1876 Cost Plan Expansion Application 30dayclean.docx	Yes	Yes	Fillable Printable
Instruction			CY2016 HSD Instructions (30day) clean.pdf	Yes	No	Fillable Printable
Form	CMS-10237	CY 2016 Medicare Advantage HSD Exception Request Template	CY2016 HSD Exception Request Template (30day) clean.pdf	Yes	Yes	Fillable Printable
Form	CMS-10237	Medicare Advantage Facility HSD Table	CY2016 CMS MA Facility HSD Table (30day) clean.pdf	Yes	Yes	Fillable Printable
Form	CMS-10237	Medicare Advantage Provider HSD Table	CY2016 CMS MA Provider 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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	566	0	566
Annual IC Time Burden (Hours)	22,625	-330	22,955
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	2016 High Levels Summary of Changes or Crosswalk of Changes (60day).pdf	10/03/2014

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