The Application for Federal Qualification (CMS 901A) Regulations in 42 CFR Section 417.140 and the Medicare Health Care Prepayment Plan Application (CMS 901D) in 42 CFR 417.800.

Forms and Documents

Document Name	Status
Supportingstatement-HCPP & FQAs 4-27.doc Supporting Statement A	2010-07-16

IC Document Collections

IC ID	Document Title	Status
8097	The Application for Federal Qualification (CMS 901A) Regulations in 42 CFR Section 417.140 and the Medicare Health Care Prepayment Plan Application (CMS 901D) in 42 CFR 417.800. Other-Medicare Health Care Prepayment Plan Application Package (	Modified

ICR Details

OMB Control No: 0938-0470	ICR Reference No: 201008-0938-002
Status: Historical Active	Previous ICR Reference No: 200704-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: The Application for Federal Qualification (CMS 901A) Regulations in 42 CFR Section 417.140 and the Medicare Health Care Prepayment Plan Application (CMS 901D) in 42 CFR 417.800.
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/19/2010
	Date Received in OIRA: 08/06/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2013	36 Months From Approved	09/30/2010
Responses	20	0	55
Time Burden (Hours)	800	0	2,200
Cost Burden (Dollars)	0	0	0

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Abstract: The application is the collection form used to obtain information to determine if an applicant meets the regulatory requirements to enter into a contract with CMS as a Federal Qualified HMO or to provide health benefits to Medicare beneficiaries as a Medicare Health Care Prepayment Plan contractor.

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Authorizing Statute(s): PL: Pub.L. 92 - 603 276 Name of Law: Social Security Amendments of 1972
   PL: Pub.L. 108 - 93 222 Name of Law: Health Maintenance of 1973
  

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:
	75 FR 25266	05/07/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 41487	07/16/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
The Application for Federal Qualification (CMS 901A) Regulations in 42 CFR Section 417.140 and the Medicare Health Care Prepayment Plan Application (CMS 901D) in 42 CFR 417.800.

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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	20	55	0	0	-35	0
Annual Time Burden (Hours)	800	2,200	0	0	-1,400	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: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $64,000

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]? Uncollected

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

Is this ICR related to the Pandemic Response? Uncollected

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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: 08/06/2010

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