Information Collection

QHP Certification

IC 206068 under ICR 201303-0938-004 · OMB 0938-1187.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1187 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10433 QHP Certification	Form and Instruction
CMS-10433 Appendix A 1 Issuer data elements 8 - Appendix A 1 Issuer data elements.pdf	Form and Instruction
CMS-10433 Appendix A 2 Program Attestations 9 - Appendix A 2 Program Attestations.pdf	Form and Instruction
CMS-10433 Appendix A 3 AdministrativeData Template 10 - Appendix A 3 AdministrativeData Template.xls	Form and Instruction
CMS-10433 Appendix A 4 EssentialCommunityProviders Template 11 - Appendix A 4 EssentialCommunityProviders Template.xls	Form and Instruction
CMS-10433 IssuerURAC 12 - IssuerURAC.xls	Form and Instruction
CMS-10433 IssuersNCQA 12 - IssuersNCQA.xls	Form and Instruction
CMS-10433 Appendix A 6 Network Adequacy Template 13 - Appendix A 6 Network Adequacy Template.xls	Form and Instruction
CMS-10433 Appendix B 1 QHP Benefit Elements 14 - Appendix B 1 QHP Benefit Elements.pdf	Form and Instruction
CMS-10433 PlansBenefits 15-PlansBenefits.xlsm	Form and Instruction
CMS-10433 PlansBenefitsAddIn 15 - PlansBenefitsAddIn.xlam	Form and Instruction
CMS-10433 Appendix B 3 PrescriptionDrug Template 16 - Appendix B 3 PrescriptionDrug Template.xls	Form and Instruction
CMS-10433 Appendix B 4 ServiceArea Template 17 - Appendix B 4 ServiceArea Template.xls	Form and Instruction
CMS-10433 Appendix C 1 Rating Tables and Issuer Business Rules 18 - Appendix C 1 Rating Tables and Issuer Business Rules .pdf	Form and Instruction
CMS-10433 Appendix C 2 RateTables Template 19 - Appendix C 2 RateTables Template.xls	Form and Instruction
CMS-10433 Appendix C 3 RatingBusinessRules Template 20 - Appendix C 3 RatingBusinessRules Template.xls	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

QHP Certification

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156.200 45 CFR 155.1065

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10433	Appendix B 4 ServiceArea Template	17 - Appendix B 4 ServiceArea Template.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Appendix A 1 Issuer data elements	8 - Appendix A 1 Issuer data elements.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Appendix A 2 Program Attestations	9 - Appendix A 2 Program Attestations.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Appendix A 3 AdministrativeData Template	10 - Appendix A 3 AdministrativeData Template.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Appendix A 4 EssentialCommunityProviders Template	11 - Appendix A 4 EssentialCommunityProviders Template.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	IssuerURAC	12 - IssuerURAC.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	IssuersNCQA	12 - IssuersNCQA.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Appendix A 6 Network Adequacy Template	13 - Appendix A 6 Network Adequacy Template.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Appendix B 1 QHP Benefit Elements	14 - Appendix B 1 QHP Benefit Elements.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	PlansBenefits	15-PlansBenefits.xlsm	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Appendix C 1 Rating Tables and Issuer Business Rules	18 - Appendix C 1 Rating Tables and Issuer Business Rules .pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	PlansBenefitsAddIn	15 - PlansBenefitsAddIn.xlam	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Appendix B 3 PrescriptionDrug Template	16 - Appendix B 3 PrescriptionDrug Template.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Appendix C 2 RateTables Template	19 - Appendix C 2 RateTables Template.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Appendix C 3 RatingBusinessRules Template	20 - Appendix C 3 RatingBusinessRules Template.xls	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: 1,240

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	Program Change Due to New Statute
Annual Number of Responses for this IC	1,240	1,240
Annual IC Time Burden (Hours)	186,186	186,186
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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