Information Collection

Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration

IC 233053 under ICR 201904-0938-016 · OMB 0938-1354.

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 MAQI Threshold Data Submission Form 2019 MAQI Threshold Data Submission Form_4-10-19_Clean.pdf	Form and Instruction
CMS-10673 MAQI Qualifying Arrangement Form 2019 MAQIQualifying Arrangement Form_4-10-2019_Clean.pdf	Form and Instruction
6c_CMS-10673_Revisions to MAQI Threshold Data Submission Form_4-10-2019.pdf Threshold Crosswalk	IC Document
2019 MAQIQualifying Arrangement Form_4-10-2019_Clean.pdf Qualifying Crosswalk	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	MAQI Threshold Data Submission Form	2019 MAQI Threshold Data Submission Form_4-10-19_Clean.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10673	MAQI Qualifying Arrangement Form	2019 MAQIQualifying Arrangement Form_4-10-2019_Clean.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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
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
Threshold Crosswalk	6c_CMS-10673_Revisions to MAQI Threshold Data Submission Form_4-10-2019.pdf	04/24/2019
Qualifying Crosswalk	2019 MAQIQualifying Arrangement Form_4-10-2019_Clean.pdf	04/24/2019

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