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Federal forms, ICRs, and supporting documents

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Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration

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

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

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Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration
 
No Modified
 
Voluntary
 

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

Health Health Care Services

 

100,000 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 100,000 0 0 0 0 100,000
Annual IC Time Burden (Hours) 1,500,000 0 0 0 0 1,500,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.