Information Collection

GenIC #3 - Alternative Benefit Plans (ABPs)

IC 220810 under ICR 201603-0938-022 · OMB 0938-1188.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1188 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10434 (#3) GenIC #3 - Alternative Benefit Plans (ABPs)	Form
CMS-10434 (#3) GenIC #3 - Screen Shots (Alternative Benefit Plans) ABP.pdf	Form
GenIC # 3 - Supporting Statement for Alternative Benefit Plans [rev 03-28-2016 by OSORA PRA].docx GenIC #3 - Supporting Statement (Alternative Benefit Plans)	IC Document

IC Title:

GenIC #3 - Alternative Benefit Plans (ABPs)

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10434 (#3)	GenIC #3 - Screen Shots (Alternative Benefit Plans)	ABP.pdf		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 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	728	728
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GenIC #3 - Supporting Statement (Alternative Benefit Plans)	GenIC # 3 - Supporting Statement for Alternative Benefit Plans [rev 03-28-2016 by OSORA PRA].docx	03/30/2016

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