Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits

Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits (CMS-10237)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0935 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10237 Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits Form and Instruction
CMS-10237 Part C -Medicare Advantage and 1876 Cost Plan Expansion 4_CY2019 Part C-MA and 1876 Cost Plan Expansion Application-Final_01162018 (rev OSORA PRA).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Applications for Part C Medicare Advantage, 1876 Cost Plans, and Employer Group Waiver Plans to Provide Part C Benefits	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 422.502 42 CFR 417.400 42 CFR 422.506 42 CFR 422.505 42 CFR 422.514 42 CFR 422.520 42 CFR 422.521 42 CFR 422.500 42 CFR 422.524 42 CFR 422.527 42 CFR 422.503 42 CFR 422.508 42 CFR 422.510 42 CFR 422.512 42 CFR 422.504 42 CFR 422.501 42 CFR 422.516

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10237	Part C -Medicare Advantage and 1876 Cost Plan Expansion Application	4_CY2019 Part C-MA and 1876 Cost Plan Expansion Application-Final_01162018 (rev OSORA PRA).pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	400	20	380
Annual IC Time Burden (Hours)	6,106	-140	6,246
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.