Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection

Essential Health Benefits Benchmark Plans

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1174 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10448 Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection Form and Instruction
Appendix_C-1_EHB Benchmark Submission Instructions 08-14-2012.docx Instruction
CMS-10448 EHB CMS State Benchmark EHBCmsStateBenchmark.xls Form and Instruction
CMS-10448 EHB Issuer Benchmark EHBIssuerBenchmark.xls Form and Instruction
CMS-10448 State Mandate Template StateMandateTemplate.xls Form and Instruction
CMS-10448 EHB Prescription Drug Template Appendix_C-3_EHB Prescription Drugs Template 07-18-2012.pdf Form and Instruction
CMs-10448 Prescription Drug Formulary PrescriptionDrugFormulary.xls Form and Instruction
CMS-10448 EHB Benefits Template Appendix_C-2_EHB Benefits Template 07-18-2012.pdf Form and Instruction
CMS-10448 EHB State Submission of State Mandates Template 508Appendix_C-5_EHB State Submission of State Mandates 05-24-2012.pdf Form and Instruction
Appendix_B_EHB_Elements 08-14-2012.docx Appendix B - Benchmark Plan Data Requirements IC Document

Information Collection (IC) Details

IC Title:	Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 156.120

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10448	EHB CMS State Benchmark	EHBCmsStateBenchmark.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	EHB Issuer Benchmark	EHBIssuerBenchmark.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	State Mandate Template	StateMandateTemplate.xls	Yes	Yes	Fillable Fileable
Instruction			Appendix_C-1_EHB Benchmark Submission Instructions 08-14-2012.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	EHB Prescription Drug Template	Appendix_C-3_EHB Prescription Drugs Template 07-18-2012.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMs-10448	Prescription Drug Formulary	PrescriptionDrugFormulary.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	EHB Benefits Template	Appendix_C-2_EHB Benefits Template 07-18-2012.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	EHB State Submission of State Mandates Template	508Appendix_C-5_EHB State Submission of State Mandates 05-24-2012.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 158	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	158	5	153
Annual IC Time Burden (Hours)	632	20	612
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix B - Benchmark Plan Data Requirements	Appendix_B_EHB_Elements 08-14-2012.docx	08/15/2012

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