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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
QHP Certification
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
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
Appendix A 1 Issuer data elements
8 - Appendix A 1 Issuer data elements.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
Appendix A 2 Program Attestations
9 - Appendix A 2 Program Attestations.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
Appendix A 3 AdministrativeData Template
10 - Appendix A 3 AdministrativeData Template.xls
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
Appendix A 4 EssentialCommunityProviders Template
11 - Appendix A 4 EssentialCommunityProviders Template.xls
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
IssuerURAC
12 - IssuerURAC.xls
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
IssuersNCQA
12 - IssuersNCQA.xls
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
Appendix A 6 Network Adequacy Template
13 - Appendix A 6 Network Adequacy Template.xls
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
Appendix B 1 QHP Benefit Elements
14 - Appendix B 1 QHP Benefit Elements.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
PlansBenefits
15-PlansBenefits.xlsm
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
PlansBenefitsAddIn
15 - PlansBenefitsAddIn.xlam
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
Appendix B 3 PrescriptionDrug Template
16 - Appendix B 3 PrescriptionDrug Template.xls
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
Appendix B 4 ServiceArea Template
17 - Appendix B 4 ServiceArea Template.xls
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
Appendix C 1 Rating Tables and Issuer Business Rules
18 - Appendix C 1 Rating Tables and Issuer Business Rules .pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
Appendix C 2 RateTables Template
19 - Appendix C 2 RateTables Template.xls
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10433
Appendix C 3 RatingBusinessRules Template
20 - Appendix C 3 RatingBusinessRules Template.xls
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:
1,240
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
1,240
1,240
0
0
0
0
Annual IC Time Burden (Hours)
186,186
186,186
0
0
0
0
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.