Information Collection

Health Insurance Cost Sharing Collection- 2020

IC 236893 under ICR 201907-0935-002 · OMB 0935-0118.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0118 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 107a Health Insurance Cost Sharing Collection- 2020	Form and Instruction
107a Attachment 107a.Protocol A (Medicare) Attachment 107a.Protocol A (Medicare)_final OMB_v2.docx	Form and Instruction
107b Attachment 107b.Protocol B (Employer) Attachment 107b.Protocol B (Employer)_final OMB_v2.docx	Form and Instruction
107c Attachment 107c.Protocol C (Private with Medicare)_ Attachment 107c.Protocol C (Private with Medicare)_final OMB_v2.docx	Form and Instruction
107d Attachment 107d.Protocol D (Other) Attachment 107d.Protocol D (Other)_final OMB_v2.docx	Form and Instruction

IC Title:

Health Insurance Cost Sharing Collection- 2020

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	107a	Attachment 107a.Protocol A (Medicare)	Attachment 107a.Protocol A (Medicare)_final OMB_v2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	107b	Attachment 107b.Protocol B (Employer)	Attachment 107b.Protocol B (Employer)_final OMB_v2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	107c	Attachment 107c.Protocol C (Private with Medicare)_	Attachment 107c.Protocol C (Private with Medicare)_final OMB_v2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	107d	Attachment 107d.Protocol D (Other)	Attachment 107d.Protocol D (Other)_final OMB_v2.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,258

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	8,135	8,135
Annual IC Time Burden (Hours)	6,101	6,101
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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