Prepaid Health Plan Cost Report

ICR 201904-0938-011

OMB: 0938-0165

Federal Form Document

Forms and Documents
Document
Name
Status
Supplementary Document
2019-04-30
Supplementary Document
2019-04-30
Supplementary Document
2019-04-30
Supplementary Document
2019-04-30
Supporting Statement A
2019-08-08
IC Document Collections
ICR Details
0938-0165 201904-0938-011
Active 201605-0938-015
HHS/CMS CMS-276
Prepaid Health Plan Cost Report
Revision of a currently approved collection   No
Regular
Approved with change 08/14/2019
Retrieve Notice of Action (NOA) 04/30/2019
  Inventory as of this Action Requested Previously Approved
08/31/2022 36 Months From Approved 12/31/2019
57 0 91
1,800 0 3,728
0 0 0

These forms are needed to establish the reasonable cost of providing covered services to the enrolled Medicare population of an HMO/CMP/HCPP in accordance with Sections 1876 and 1833 of the Social Security Act.

US Code: 42 USC 417 Name of Law: Health Maintenance Organizations, Competitive Medical Plans, and Health Care Prepayment Plans
  
None

Not associated with rulemaking

  84 FR 731 01/31/2019
84 FR 15615 04/16/2019
No

2
IC Title Form No. Form Name
Prepaid Health Plan Cost Report (HCPPS) CMS-276, CMS-276, CMS-276, CMS-276 4th Quarter Interim Cost Report ,   Budget Forecast ,   Semi Annual Cost Report ,   Final Cost Report
Prepaid Health Plan Cost Report (HMO) CMS-276, CMS-276, CMS-276, CMS-276 Budget Forecast ,   Interim Report ,   4th Quarter Interim Report ,   Final Cost Report

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 57 91 0 -10 -24 0
Annual Time Burden (Hours) 1,800 3,728 0 -1,928 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
6 cost-based MCOs have terminated, which has affected the estimated total number of respondents. As a result, the estimated number of respondents for HMO/CMPs have been reduced from 16 to 10 since our last submission. Additionally, at this time, 4th quarter interim reports are waived from submission by CMS.

$75,872
No
    No
    No
No
No
No
Uncollected
Kayla Williams 410 786-5887 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
04/30/2019


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