Information Collection

State Governments

IC 216793 under ICR 202609-0938-004 · OMB 0938-1281.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10553 Alternative MAC QRS Methodology Request Template State Governments	Form and Instruction
Form CMS-10553 Implementation Extension Request Template A: Methodology State Governments	Form and Instruction
Form Appendix A Appendix A: Additional State Managed Care Plan Landscape Tables State Governments	Form and Instruction
CMS-10553 Alternative MAC QRS Methodology Request Template Alternative Methodology Request Template_OGD Approved_04.15.26.docx	Form and Instruction
CMS-10553 Implementation Extension Request Template A: Methodology Methodology Extension Request Template_OGD Approved_4.docx	Form and Instruction
Appendix A Appendix A: Additional State Managed Care Plan Landscape Appendix A Managed Care Landscape Tables_To CMS_04.15.26.docx	Form and Instruction

IC Title:

State Governments

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 438.340 42 CFR 438.330 42 CFR 438.332 42 CFR 438.310 42 CFR 438.334

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10553	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10553	Yes	Yes	Fillable Fileable
Form and Instruction	Appendix A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 44

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,959	-1	2,960
Annual IC Time Burden (Hours)	91,678	2,054	89,624
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.

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