Information Collection

#79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template

IC 258773 under ICR 202401-0938-016 · OMB 0938-1148.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1148 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10398 #79 #79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template	Form and Instruction
Form CMS-10398 #79 #79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template	Form and Instruction
COVID-19 Frequently Asked Questions (FAQs).pdf	Other-Frequently Asked Questions (FA
COVID-19 Frequently Asked Questions (FAQs).pdf	Other-Frequently Asked Questions (FA
CMCS Outreach Email_2023-01-10.docx	Other-CMCS Outreach Email
CMCS Outreach Email_2023-01-10.docx	Other-CMCS Outreach Email
HI Risk Mitigation Approval Letter 12202021.pdf	Other-Sample Section 1115 Approval L
HI Risk Mitigation Approval Letter 12202021.pdf	Other-Sample Section 1115 Approval L
CMS-10398 #79 COVID-19 Risk Corridor Reconciliation Reporting Template COVID-19 Risk Corridor Reconciliation Reporting Template.xlsm	Form and Instruction
CMS-10398 #79 COVID-19 Risk Corridor Reconciliation Reporting Template COVID-19 Risk Corridor Reconciliation Reporting Template.xlsm	Form and Instruction
#79 - Generic Supporting Statement (2023 version 8).docx Generic Supporting Statement	IC Document
#79 - Generic Supporting Statement (2023 version 8).docx Generic Supporting Statement	IC Document

IC Title:

#79 (New): COVID-19 Risk Corridor Reconciliation Reporting Template

Agency IC Tracking Number:

CMCS

IC Status: Unchanged

Obligation to Respond: Mandatory

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	CMS-10398 #79	COVID-19 Risk Corridor Reconciliation Reporting Template	COVID-19 Risk Corridor Reconciliation Reporting Template.xlsm	Yes	Yes	Fillable Fileable
Other-Frequently Asked Questions (FAQs)			COVID-19 Frequently Asked Questions (FAQs).pdf	Yes	No	Printable Only
Other-CMCS Outreach Email			CMCS Outreach Email_2023-01-10.docx	Yes	No	Printable Only
Other-Sample Section 1115 Approval Letter			HI Risk Mitigation Approval Letter 12202021.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	90	90
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Supporting Statement	#79 - Generic Supporting Statement (2023 version 8).docx	02/25/2023

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