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Federal forms, ICRs, and supporting documents

Information Collection

Health Maintenance Organizations (HMOs) and Competitive Medical Plans (CMPs) under Section 1876

IC 190488 under ICR 202507-0938-025 · OMB 0938-0165.

Documents and Forms
Document Name
Document Type
Form
Form
Form
Form
Instruction
Instruction
Form
Form
Form
Form
Form
Form
Form
Form
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Health Maintenance Organizations (HMOs) and Competitive Medical Plans (CMPs) under Section 1876
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 417.572 42 CFR 417.576

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction C. Cost Report Instructions CLEAN 508.pdf Yes No Fillable Fileable
Form CMS-276 Budget Forecast E. Budget Forecast- Revised 508.pdf Yes Yes Fillable Fileable
Form CMS-276 Interim Cost Report H. Interim Cost Report - Revised 508.pdf Yes Yes Fillable Fileable
Form CMS-276 4th Quarter Interim Report K. 4th Quarter Interim Cost Report - Revised 508.pdf Yes Yes Fillable Fileable
Form CMS-276 Final Cost Report N. Final Cost Report PDF 508.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

6 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 18 0 -9 0 0 27
Annual IC Time Burden (Hours) 648 0 -324 0 0 972
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk: Instructions C. Cost Report Instruction Crosswalk 508.pdf 07/29/2025
Crosswalk: Budget Forecast F. Budget Forecast Crosswalk 508.pdf 07/29/2025
Crosswalk: Interim Cost Report I. Interim Cost Report Crosswalk 508.pdf 07/29/2025
Crosswalk: 4th Quarter Interim Cost Report L. 4thQtrInterim Revised Cost Rep Crosswalk 508.pdf 07/29/2025
Crosswalk: Final Cost Report O. Final Cost Report Crosswalk 508.pdf 07/29/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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