Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
QHP Certification New 1240 186186 0 Form and Instruction CMS-10433 Appendix A 1 Issuer data elements
Form and Instruction CMS-10433 Appendix A 2 Program Attestations
Form and Instruction CMS-10433 Appendix A 3 AdministrativeData Template
Form and Instruction CMS-10433 Appendix A 4 EssentialCommunityProviders Template
Form and Instruction CMS-10433 IssuerURAC
Form and Instruction CMS-10433 IssuersNCQA
Form and Instruction CMS-10433 Appendix A 6 Network Adequacy Template
Form and Instruction CMS-10433 Appendix B 1 QHP Benefit Elements
Form and Instruction CMS-10433 PlansBenefits
Form and Instruction CMS-10433 PlansBenefitsAddIn
Form and Instruction CMS-10433 Appendix B 3 PrescriptionDrug Template
Form and Instruction CMS-10433 Appendix B 4 ServiceArea Template
Form and Instruction CMS-10433 Appendix C 1 Rating Tables and Issuer Business Rules
Form and Instruction CMS-10433 Appendix C 2 RateTables Template
Form and Instruction CMS-10433 Appendix C 3 RatingBusinessRules Template
Reinsurance New 1600 13333 0 Form and Instruction CMS-10433 Appendix D 1 RI, RA, Banking, Edge Server Data Elements
Reinsurance and Risk Adjustment New 600 3800 0 Form and Instruction CMS-10433 Appendix D 1 RI, RA, Banking, Edge Server Data Elements
States New 50 150 0
Total burden requested under this ICR: 3490 203469 0  
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