Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration

(CMS-10673) Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.