View Information Collection (IC)

View Information Collection (IC)

IC Title:	Basic Health Plan State Report for Health Insurance Exchange Premiums	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-PRA Disclosure Statement			BHP Disclosure Statement 11182013.doc		Yes	No	Printable Only
Form and Instruction	CMS-10510	BHP State Report for Exchnage Premiums	Copy of BHP State Report for Exchange Premiums 4-7-2014.pdf		Yes	Yes	Fillable Printable

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: 17	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	17	0	0	0	0	17
Annual IC Time Burden (Hours)	68	0	0	0	0	68
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk 4 7 2014 (rev 6-27-2014 by OSORA PRA).xlsx	06/27/2014

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