View Information Collection (IC)

View Information Collection (IC)

IC Title:	EHB Reporting	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 156.111(e)(1)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10488	EHB Confirmation Template	CMS-10448_ Appendix A EHB BM Plans 2019_State EHB Confirmation Template.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	EHB Benchmark Plan Certification	CMS-10448_ Appendix B EHB Benchmark Plan Cert.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	Benchmark Plans Prescription Template	CMS-10448_ Appendix D EHB BM Plans_Rx Template.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	Summary of Benefits Template	CMS-10448_ Appendix C EHB BM Plans 2019_Summary of Benefits Template.pdf		Yes	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	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	400	10	0	390	0	0
Annual IC Time Burden (Hours)	470	399	0	71	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix E - Benchmark Plans 2019 EHB Chart - Information Only	CMS-10448_ Appendix E EHB BM Plans 2019_EHB Chart.pdf	04/17/2018

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