Health Insurance Cost Sharing Collection- 2020

Medical Expenditure Panel Survey (MEPS) COVID-19 Changes

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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
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
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
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
107d Attachment 107d.Protocol D (Other) Attachment 107d.Protocol D (Other)_final OMB_v2.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Health Insurance Cost Sharing Collection- 2020	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	Approved	Previously Approved
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

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.