View Information Collection (IC)

View Information Collection (IC)

QHP Certification
 
No New
 
Required to Obtain or Retain Benefits
 
45 CFR 156.200 45 CFR 155.1065

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10433 Appendix A 1 Issuer data elements 8 - Appendix A 1 Issuer data elements.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10433 Appendix A 2 Program Attestations 9 - Appendix A 2 Program Attestations.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10433 Appendix A 3 AdministrativeData Template 10 - Appendix A 3 AdministrativeData Template.xls Yes Yes Fillable Fileable
Form and Instruction CMS-10433 Appendix A 4 EssentialCommunityProviders Template 11 - Appendix A 4 EssentialCommunityProviders Template.xls Yes Yes Fillable Fileable
Form and Instruction CMS-10433 IssuerURAC 12 - IssuerURAC.xls Yes Yes Fillable Fileable
Form and Instruction CMS-10433 IssuersNCQA 12 - IssuersNCQA.xls Yes Yes Fillable Fileable
Form and Instruction CMS-10433 Appendix A 6 Network Adequacy Template 13 - Appendix A 6 Network Adequacy Template.xls Yes Yes Fillable Fileable
Form and Instruction CMS-10433 Appendix B 1 QHP Benefit Elements 14 - Appendix B 1 QHP Benefit Elements.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10433 PlansBenefits 15-PlansBenefits.xlsm Yes Yes Fillable Fileable
Form and Instruction CMS-10433 PlansBenefitsAddIn 15 - PlansBenefitsAddIn.xlam Yes Yes Fillable Fileable
Form and Instruction CMS-10433 Appendix B 3 PrescriptionDrug Template 16 - Appendix B 3 PrescriptionDrug Template.xls Yes Yes Fillable Fileable
Form and Instruction CMS-10433 Appendix B 4 ServiceArea Template 17 - Appendix B 4 ServiceArea Template.xls Yes Yes Fillable Fileable
Form and Instruction CMS-10433 Appendix C 1 Rating Tables and Issuer Business Rules 18 - Appendix C 1 Rating Tables and Issuer Business Rules .pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10433 Appendix C 2 RateTables Template 19 - Appendix C 2 RateTables Template.xls Yes Yes Fillable Fileable
Form and Instruction CMS-10433 Appendix C 3 RatingBusinessRules Template 20 - Appendix C 3 RatingBusinessRules Template.xls Yes Yes Fillable Fileable

Health Health Care Services

 

1,240 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,240 1,240 0 0 0 0
Annual IC Time Burden (Hours) 186,186 186,186 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.