View Information Collection (IC)

View Information Collection (IC)

IC Title:	QHP Certification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.1065 45 CFR 156.200

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10433	Administrative Data Template	CMS-10433 - Appendix A-Accred-Admin-Screenshots.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Network Adequacy Template	AppK_NONFUNCTIONAL_EcpNetworkAdequacyTemplate.xlsm		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Plan Benefits Template	AppC_NONFUNCTIONAL_PlanCW-Template.xlsm		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Network ID Template	AppB_NONFUNCTIONAL_Networka.xls		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Plans and Benefits Template	AppD_NONFUNCTIONAL_PlansBenefits.xlsm		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Prescriptions Drug Formulary Template	AppE_NONFUNCTIONAL_PrescriptionDrug.xls		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Rate Table Template	AppG_NONFUNCTIONAL_RateTables.xls		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Service Area Template	AppI_NONFUNCTIONAL_ServiceArea.xls		Yes	Yes	Fillable Fileable
Form and Instruction	CMs-10433	Business Rules Template	AppH_NONFUNCTIONAL_RatingBusinessRules.xls		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	QHP Certification Instrument Screenshots	CMS-10433 - AppJ -Transparency.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Reinsurance Program and Risk Adjustment Program	CMS-10433 - Appendix F-RA-Programs-Payment-Ops-Data.pdf		Yes	Yes	Fillable Fileable

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: 200	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 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	200	0	0	-500	0	700
Annual IC Time Burden (Hours)	39,200	0	0	-69,000	0	108,200
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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