Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
QHP Certification Modified 700 108200 0 Form and Instruction CMS-10433 Administrative Data Template
Form and Instruction CMS-10433 Network Adequacy Template
Form and Instruction CMS-10433 NCQA Template
Form and Instruction CMS-10433 Network ID Template
Form and Instruction CMS-10433 Plans and Benefits Template
Form and Instruction CMS-10433 Prescriptions Drug Formulary Template
Form and Instruction CMS-10433 Rate Table Template
Form and Instruction CMS-10433 Service Area Template
Form and Instruction CMs-10433 Business Rules Template
Form and Instruction CMS-10433 QHP Certification Instrument Screenshots
Form and Instruction CMS-10433 Reinsurance Program and Risk Adjustment Program
Reinsurance Unchanged 23800 119000 0 Instruction
Reinsurance and Risk Adjustment Modified 2400 7800 0 Form and Instruction CMS-10433 Reinsurance and Risk Adjustment Bank Server
States Modified 51 153 0
Total burden requested under this ICR: 26951 235153 0  
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