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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.