Information Collection

#18: Alternative Benefit Plans

IC 214319 under ICR 201410-0938-016 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10398 (#18) #18: Alternative Benefit Plans Form
CMS-10398 (#18) Interim Form for Alternative Benefit Plans ABP MockUp_Final_7_2_13 [rev 7-3-2013 by OSORA PRA].docx Form
#18 Alternative Benefit Plans Supporting Statement [Dec 2014].docx #18 Supporting Statement: Alternative Benefit Plans IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	#18: Alternative Benefit Plans	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10398 (#18)	Interim Form for Alternative Benefit Plans	ABP MockUp_Final_7_2_13 [rev 7-3-2013 by OSORA PRA].docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	448	448
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
#18 Supporting Statement: Alternative Benefit Plans	#18 Alternative Benefit Plans Supporting Statement [Dec 2014].docx	12/22/2014

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