Form CMS-10448 Notice of Intent to Provide Dental Coverage in the Excha

Essential Health Benefits Benchmark Plans

508Appendix_C-4_EHB Draft Dental NOI 20120516

EHB Dental Plan Issuers

OMB: 0938-1174

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1174 can be found here:

2024-08-09 - Reinstatement with change of a previously approved collection
2024-02-13 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

Notice of Intent to Provide Dental Coverage in the Exchange

Issuer Name:

Please lists the State or States in which the
issuer intendeds to offer coverage in an
Exchange as a stand-alone dental plan:
Please complete the following information for each State in which the issuer intendeds to offer dental coverage.
State:
Individual Market Intended Participation:
Small Group Market Intended Participation:
Individual Market Intended Service Area:
Small Group Market Indended Service Area:

File Type	application/pdf
File Title	Draft Dental Plan Notice of Intent Template
Author	CMS
File Modified	2012-07-29
File Created	2012-05-21