Information Collection

GenIC #3 - Alternative Benefit Plans (ABPs)

IC 220810 under ICR 201708-0938-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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: Unchanged

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	Previously Approved
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.