Information Collection

Prepaid Health Plan Cost Report (HMO)

IC 190488 under ICR 202203-0938-008 · OMB 0938-0165.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0165 can be found here:

Documents and Forms

Document Name Document Type
C. Cost Report Instructions vj508.pdf Instruction
C. Cost Report Instructions vj508.pdf Instruction
CMS-276 Budget Forecast E. Budget Forecast - Revised VJ508.pdf Form
CMS-276 Budget Forecast E. Budget Forecast - Revised VJ508.pdf Form
CMS-276 Interim Report H. Interim Cost Report - Revised VJ508.pdf Form
CMS-276 Interim Report H. Interim Cost Report - Revised VJ508.pdf Form
CMS-276 4th Quarter Interim Report K. 4th Quarter Interim Cost Report - Revised VJ508.pdf Form
CMS-276 4th Quarter Interim Report K. 4th Quarter Interim Cost Report - Revised VJ508.pdf Form
CMS-276 Final Cost Report N. Final Cost Report - Revised VJ508.pdf Form
CMS-276 Final Cost Report N. Final Cost Report - Revised VJ508.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Prepaid Health Plan Cost Report (HMO)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 417.572 42 CFR 417.576

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			C. Cost Report Instructions vj508.pdf	Yes	No	Fillable Fileable
Form	CMS-276	Budget Forecast	E. Budget Forecast - Revised VJ508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-276	Interim Report	H. Interim Cost Report - Revised VJ508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-276	4th Quarter Interim Report	K. 4th Quarter Interim Cost Report - Revised VJ508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-276	Final Cost Report	N. Final Cost Report - Revised VJ508.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	27	-3	30
Annual IC Time Burden (Hours)	972	-108	1,080
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.