Information Collection

Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)

IC 186438 under ICR 202004-0938-001 · OMB 0938-1051.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1051 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
HPMS User Guide Extract for CMS-10260.docx	Instruction
CY2021_Clean_1_HMO_MAPD_ISNP_CSNP_ANOC_03162020.docx	Instruction
CY2021_Clean_2_PPO_MAPD_ISNP_CSNP_ANOC_03162020.docx	Instruction
CY2021_Clean_3_DE_SNP_ANOC_03162020.docx	Instruction
CY2021_Clean_4_Cost_Plan_ANOC_03162020.docx	Instruction
CY2021_Clean_5_PFFS_ANOC_03162020.docx	Instruction
CY2021_Clean_6_MSA_ANOC_03162020.docx	Instruction
CY2021_Clean_7_HMO_MA_ANOC_03162020.docx	Instruction
CY2021_Clean_8_PPO_MA_ANOC_03162020.docx	Instruction
CY2021_Clean_9_PDP_ANOC_03162020.docx	Instruction
CY2021_Clean_1_HMO_MAPD_ISNP_CSNP_EOC_03162020.docx	Instruction
CY2021_Clean_2_PPO_MAPD_ISNP_CSNP_EOC_03162020.docx	Instruction
CY2021_Clean_3_DE_SNP_EOC_03162020.docx	Instruction
CY2021_Clean_4_Cost_Plan_EOC_03162020.docx	Instruction
CY2021_Clean_5_PFFS_EOC_03162020.docx	Instruction
CY2021_Clean_6_MSA_EOC_03162020.docx	Instruction
CY2021_Clean_7_HMO_MA_EOC_03162020.docx	Instruction
CY2021_Clean_8_PPO_MA_EOC_03162020.docx	Instruction
CY2021_Clean_9_PDP_EOC_03162020.docx	Instruction

IC Title:

Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)

Agency IC Tracking Number:

CM-CPC

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 423.128(a)(3) 42 CFR 422.111(a)(3)

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Electronic Capability
Instruction	CY2021_Clean_1_HMO_MAPD_ISNP_CSNP_ANOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_4_Cost_Plan_EOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_8_PPO_MA_EOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_9_PDP_EOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_2_PPO_MAPD_ISNP_CSNP_ANOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_3_DE_SNP_ANOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_4_Cost_Plan_ANOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_5_PFFS_ANOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_6_MSA_ANOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_7_HMO_MA_ANOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_8_PPO_MA_ANOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_9_PDP_ANOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_1_HMO_MAPD_ISNP_CSNP_EOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_2_PPO_MAPD_ISNP_CSNP_EOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_3_DE_SNP_EOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_5_PFFS_EOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_6_MSA_EOC_03162020.docx	No	Fillable Fileable
Instruction	CY2021_Clean_7_HMO_MA_EOC_03162020.docx	No	Fillable Fileable
Instruction	HPMS User Guide Extract for CMS-10260.docx	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 795

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	795	-10	805
Annual IC Time Burden (Hours)	9,540	-120	9,660
Annual IC Cost Burden (Dollars)	42,000,000	-8,026,730,000	8,068,730,000

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.