Information Collection

GenIC#18 - Medicare Advantage Regional Outreach Experiment Survey

IC 234140 under ICR 201708-0938-025 · OMB 0938-1247.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1247 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10437- GenIC#1 GenIC#18 - Medicare Advantage Regional Outreach Experiment Survey	Form and Instruction
CMS-10437- GenIC#1 Medicare Advantage Regional Outreach Experiment Survey ( CMS-10437#18.Medicare Advantage Survey_OnlineVersion_101918.docx	Form and Instruction
CMS-1037 GenIC#18 CMS-10437#18.Medicare Advantage Survey (Telephone Versio CMS-10437#18.Medicare Advantage Survey_TelephoneVersion_101918.docx	Form and Instruction
CMS-10437#18.MAExperiment_SupportingStatement_FINAL - 11-26-18.docx CMS-10437#18.MAExperiment_SupportingStatement_FINAL - 11-26-18	IC Document
CMS-10437#18. MAExperiment_CoverPage_101918.docx CMS-10437#18. MAExperiment_CoverPage	IC Document

IC Title:

GenIC#18 - Medicare Advantage Regional Outreach Experiment Survey

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

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 and Instruction	CMS-10437- GenIC#18	Medicare Advantage Regional Outreach Experiment Survey (Online Version)	CMS-10437#18.Medicare Advantage Survey_OnlineVersion_101918.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-1037 GenIC#18	CMS-10437#18.Medicare Advantage Survey (Telephone Version)	CMS-10437#18.Medicare Advantage Survey_TelephoneVersion_101918.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,600	1,600
Annual IC Time Burden (Hours)	267	267
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CMS-10437#18.MAExperiment_SupportingStatement_FINAL - 11-26-18	CMS-10437#18.MAExperiment_SupportingStatement_FINAL - 11-26-18.docx	11/26/2018
CMS-10437#18. MAExperiment_CoverPage	CMS-10437#18. MAExperiment_CoverPage_101918.docx	11/26/2018

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