Information Collection

Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection

IC 203739 under ICR 201303-0938-003 · OMB 0938-1174.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10448 EHB CMS State Benchmark Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Form and Instruction
Form CMS-10448 EHB Issuer Benchmark Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Form and Instruction
Form CMS-10448 State Mandate Template Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Form and Instruction
Form CMS-10448 EHB Prescription Drug Template Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Form and Instruction
Form CMs-10448 Prescription Drug Formulary Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Form and Instruction
Form CMS-10448 EHB Benefits Template Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Form and Instruction
Form CMS-10448 EHB State Submission of State Mandates Template 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

View Information Collection (IC)

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10448	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	Yes	Yes	Fillable Fileable
Form and Instruction	CMs-10448	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	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: 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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Appendix B - Benchmark Plan Data Requirements		08/15/2012

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].