Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
QHP Certification Modified 215 42140 0 Form and Instruction CMS-10433 Administrative Data Template
Form and Instruction CMS-10433 Plan Benefits Template
Form and Instruction CMS-10433 Network ID Template
Form and Instruction CMS-10433 Plans and Benefits Template
Form and Instruction CMS-10433 Prescriptions Drug Formulary Template
Form and Instruction CMS-10433 Rate Table Template
Form and Instruction CMS-10433 Service Area Template
Form and Instruction CMs-10433 Business Rules Template
Form and Instruction CMS-10433 QHP Certification Instrument Screenshots
Form and Instruction CMS-10433 Reinsurance Program and Risk Adjustment Program
Risk Adjustment Modified 2400 7800 0 Form and Instruction CMS-10433 Reinsurance and Risk Adjustment Bank Server
Stand-Alone Dental Issuers: QHP Certification Modified 270 21600 0
States: SBE's, Federal Platform and Partnership States Modified 40 120 0
Total burden requested under this ICR: 2925 71660 0  
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