Prepaid Health Plan Cost Report

Forms and Documents

Document Name	Status
CMS-276 Supporting Statement Part A - Passback3.doc Supporting Statement A	2016-11-25
O. Crosswalk for Final Cost Report.doc Supplementary Document	2016-05-18
L. Crosswalk for 4th Quarter Interim Cost Report.doc Supplementary Document	2016-05-18
I. Crosswalk for Interim-Final Version.doc Supplementary Document	2016-05-18
F. Crosswalk for Budget Forecast -Final Verision.doc Supplementary Document	2016-05-18

IC Document Collections

IC ID	Document Title	Status
43653	Prepaid Health Plan Cost Report (HCPPS) Instruction	Modified
190488	Prepaid Health Plan Cost Report (HMO) Instruction	Modified

ICR Details

OMB Control No: 0938-0165	ICR Reference No: 201605-0938-015
Status: Historical Active	Previous ICR Reference No: 201305-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-276
Title: Prepaid Health Plan Cost Report
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/02/2016
	Date Received in OIRA: 05/27/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved	12/31/2016
Responses	91	0	106
Time Burden (Hours)	3,728	0	4,372
Cost Burden (Dollars)	0	0	0

---

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.

---

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

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 7124	02/10/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 22272	04/15/2016
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Prepaid Health Plan Cost Report (HMO)	CMS-276, CMS-276, CMS-276, CMS-276	Interim Report ,   4th Quarter Interim Report ,   Budget Forecast ,   Final Cost Report
Prepaid Health Plan Cost Report (HCPPS)	CMS-276, CMS-276, CMS-276, CMS-276	Prepaid Health Plan Cost Report ,   Budget Forecast ,   Semi Annual Cost Report ,   Final Cost Report

---

ICR Summary 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	91	106	0	-15	0	0
Annual Time Burden (Hours)	3,728	4,372	0	-644	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: There were no program changes. There were only minor changes to the worksheets and instructions. The burden hours were impacted because of a reduction in respondents. These changes do not impact the preparation time to complete the worksheets.

---

Annual Cost to Federal Government: $136,976

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

---

Common Form ICR:  No

---

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: 05/27/2016

---