Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration

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

Documents and Forms

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

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: Modified

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	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 %

	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

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.