Information Collection

Health Insurance Issuer Submission of the Preliminary Justification

IC 198019 under ICR 201106-0938-008 · OMB 0938-1141.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1141 can be found here:

Documents and Forms

Document Name Document Type
Preliminary Justification Submission Function.docx Other-Word Document
CMS-10379.Rate_Summary_Form_(7-12-11)_w_comment_changes_highlighted.xls Rate Summary Worksheet IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Insurance Issuer Submission of the Preliminary Justification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Word Document			Preliminary Justification Submission Function.docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 974	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
Annual Number of Responses for this IC	974	974
Annual IC Time Burden (Hours)	10,714	10,714
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Rate Summary Worksheet	CMS-10379.Rate_Summary_Form_(7-12-11)_w_comment_changes_highlighted.xls	08/15/2011

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