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 156.200 45 CFR 155.1065

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	Plan Benefits Template	C_Plan_ID_Crosswalk_Template.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Network ID Template	B_URL_Template.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Plans and Benefits Template	D_Plans_and_Benefits_Template.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Prescriptions Drug Formulary Template	E_Perscrption_Drug_Template.pdf		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	I_Service_Area_Template.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMs-10433	Business Rules Template	H_Business_Rules_Template.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	QHP Certification Instrument Screenshots	J_Interoperability_Compliance_Web_ Form.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Reinsurance Program and Risk Adjustment Program	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: 215	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	215	0	0	15	0	200
Annual IC Time Burden (Hours)	42,140	0	0	2,940	0	39,200
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.