View Information Collection (IC)

View Information Collection (IC)

EHB Reporting - EHB Actuarial Certificate Template
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 156.111(e)(2)

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 AppA-StateConfirm.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10448 EHB Benchmark Plan Certification AppB-EHB-BM-Certif.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10448 Benchmark Plans Prescription Template AppD-EHB-BM-PlanRx.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10448 Summary of Benefits Template AppC-EHB-BM-2019-BenefSumm-508.pdf Yes No Paper Only
Form and Instruction CMS-10448 EHB Benchmark Plan Certificate CMS-10448_Appendix_B_EHB_Benchmark_Plan_Certificate_508.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

5 0
   
State, Local, and Tribal Governments
 
   0 %

  Requested 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 5 0 0 -5 0 10
Annual IC Time Burden (Hours) 60 0 0 13 0 47
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.