Information Collection

Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration

IC 233053 under ICR 201809-0938-002 · OMB 0938-1354.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1354 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10673 Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration	Form and Instruction
CMS-10673 Qualifying Payment Arrangement Form CMS-10673 MAQI Qualifying Payment Arrangement Form_9.5.18_Final.pdf	Form and Instruction
CMS-10673 Threshold Data Submission Form CMS-10673 MAQI Threshold Data Submission Form 9.5.18_Final.pdf	Form and Instruction
CMS-10673 Crosswalk - MAQI Threshold Data Submission Form.pdf Crosswalk - Threshold Data Submission Form	IC Document
CMS-10673_Crosswalk MAQI Qualifying Payment Arrangement Form.pdf Crosswalk - Qualifying Payment Arrangement Form	IC Document

IC Title:

Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration

Agency IC Tracking Number:

Is this a Common Form? No

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-10673	Qualifying Payment Arrangement Form	CMS-10673 MAQI Qualifying Payment Arrangement Form_9.5.18_Final.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10673	Threshold Data Submission Form	CMS-10673 MAQI Threshold Data Submission Form 9.5.18_Final.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100,000	100,000
Annual IC Time Burden (Hours)	1,500,000	1,500,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk - Threshold Data Submission Form	CMS-10673 Crosswalk - MAQI Threshold Data Submission Form.pdf	09/18/2018
Crosswalk - Qualifying Payment Arrangement Form	CMS-10673_Crosswalk MAQI Qualifying Payment Arrangement Form.pdf	09/18/2018

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