Prepaid Health Plan Cost Report (CMS-276)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-276 Final Cost Report	Form	Modified	Repair queued
Form CMS-276 Interim Cost Report	Form	Modified	Available
Form CMS-276 Budget Forecast	Form	Modified	Available
Form CMS-276 4th Quarter Interim Cost Report	Form	Modified	Available
Form CMS-276 Final Cost Report	Form	Modified	Repair queued
Form CMS-276 4th Quarter Interim Report	Form	Modified	Available
Form CMS-276 Interim Cost Report	Form	Modified	Available
Form CMS-276 Budget Forecast	Form	Modified	Repair queued
CMS-276 - Supporting Statement A (2025 version 8).docx	Supporting Statement A	Uploaded 2025-07-29	Repair queued
CMS-276 - Supporting Statement A (2025 version 8).docx	Supporting Statement A	Uploaded 2025-07-29	Repair queued
Comment - mab-mtzm-jyxs.pdf	Public Comments	Uploaded 2025-05-05	Available
Comment - maw-vgv5-lo78.pdf	Public Comments	Uploaded 2025-05-20	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43653	Health Care Prepayment Plans (HCPPs) under Section 1833	Form	Modified	Final Cost Report
43653	Health Care Prepayment Plans (HCPPs) under Section 1833	Form	Modified	Interim Cost Report
43653	Health Care Prepayment Plans (HCPPs) under Section 1833	Form	Modified	Budget Forecast
43653	Health Care Prepayment Plans (HCPPs) under Section 1833	Form	Modified	4th Quarter Interim Cost Report
43653	Health Care Prepayment Plans (HCPPs) under Section 1833	Instruction	Modified
190488	Health Maintenance Organizations (HMOs) and Competitive Medical Plans (CMPs) under Section 1876	Form	Modified	Final Cost Report
190488	Health Maintenance Organizations (HMOs) and Competitive Medical Plans (CMPs) under Section 1876	Form	Modified	4th Quarter Interim Report
190488	Health Maintenance Organizations (HMOs) and Competitive Medical Plans (CMPs) under Section 1876	Form	Modified	Interim Cost Report
190488	Health Maintenance Organizations (HMOs) and Competitive Medical Plans (CMPs) under Section 1876	Form	Modified	Budget Forecast
190488	Health Maintenance Organizations (HMOs) and Competitive Medical Plans (CMPs) under Section 1876	Instruction	Modified

ICR Details

OMB Control No: 0938-0165	ICR Reference No: 202507-0938-025
Status: Active	Previous ICR Reference No: 202203-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No: OFM
Title: Prepaid Health Plan Cost Report (CMS-276)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/23/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/29/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2028	36 Months From Approved	12/31/2025
Responses	36	0	51
Time Burden (Hours)	1,128	0	1,612
Cost Burden (Dollars)	0	0	0

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Abstract: These forms are needed to establish the reasonable cost of providing covered services to the enrolled Medicare population of an HMO/CMP/HCPP in accordance with Sections 1876 and 1833 of the Social Security Act.

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Authorizing Statute(s): US Code: 42 USC 417 Name of Law: Health Maintenance Organizations, Competitive Medical Plans, and Health Care Prepayment Plans
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 13367	03/21/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 25046	06/13/2025
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Health Care Prepayment Plans (HCPPs) under Section 1833	CMS-276, CMS-276, CMS-276, CMS-276	4th Quarter Interim Cost Report ,   Budget Forecast ,   Interim Cost Report ,   Final Cost Report
Health Maintenance Organizations (HMOs) and Competitive Medical Plans (CMPs) under Section 1876	CMS-276, CMS-276, CMS-276, CMS-276	Budget Forecast ,   Interim Cost Report ,   4th Quarter Interim Report ,   Final Cost Report

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	36	51	0	-15	0	0
Annual Time Burden (Hours)	1,128	1,612	0	-484	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This iteration proposes minor changes to the worksheets and instructions (see the attached Crosswalks for details). The changes have no impact on our per response time estimates. Since our last submission to OMB, two cost-based MCOs have terminated, which has affected the estimated total number of respondents. As a result, the estimated number of respondents for HMO/CMPs have been reduced by minus 3 (from 9 to 6) since our last submission, and the number of respondents for HCPPs have been reduced by minus 2 (from 8 to 6). As such, our total time estimate decreased by minus 484 hours (from 1,612 hr to 1,128 hr).

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Annual Cost to Federal Government: $38,688

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/29/2025

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