Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
EHB Dental Plan Issuers Modified 175 88 0
EHB Reporting Modified 10 47 0 Form and Instruction CMS-10488 EHB Confirmation Template
Form and Instruction CMS-10448 EHB Benchmark Plan Certification
Form and Instruction CMS-10448 Benchmark Plans Prescription Template
Form and Instruction CMS-10448 Summary of Benefits Template
EHB Substitution Modified 5 3 0 Form and Instruction CMS-10488 Substitution Notification
Form and Instruction CMS-10448 State Documentation Requirements
Reporting - State Mandates Modified 41 19 0 Form and Instruction CMS-10448 State Annual Report
Form and Instruction CMS-10448 State Certification Annual Report (SBRs)
Total burden requested under this ICR: 231 157 0  
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