Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491

(CMS-1561/1561A) Health Insurance Benefit Agreement and Supporting Regulations

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0832 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-1561 Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491 Form and Instruction
CMS-1561 Health Insurance Benefits Agreement cms1561 508 compliant 4-3-17.pdf Form and Instruction
CMS-1561A Health Insurance Benefits Agreement for RHC CMS1561A 508 compliant 4-3-17.pdf Form and Instruction
CMS-1561 Burden Estimate 01.05.18.docx Burden Estimates IC Document

Information Collection (IC) Details

IC Title:	Health Insurance Benefit Agreement and Supporting Regulations at 42 CFR Part 489 and 491	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 489 42 CFR 491

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1561	Health Insurance Benefits Agreement	cms1561 508 compliant 4-3-17.pdf		No		Paper Only
Form and Instruction	CMS-1561A	Health Insurance Benefits Agreement for RHC	CMS1561A 508 compliant 4-3-17.pdf		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,454	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,454	0	-546	3,000
Annual IC Time Burden (Hours)	2,454	1,636	318	500
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Burden Estimates	CMS-1561 Burden Estimate 01.05.18.docx	01/11/2018

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