Information Collection

Basic Health Plan State Report for Health Insurance Exchange Premiums

IC 209843 under ICR 201312-0938-015 · OMB 0938-1218.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1218 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10510 Basic Health Plan State Report for Health Insurance Exchange Premiums	Form and Instruction
BHP Disclosure Statement 11182013.doc	Other-PRA Disclosure Statement
CMS-10510 BHP State Report for Health Insurance Exchange Premiums BHP State Report for Exchange Premiums 11-20-2013 final.xlsx	Form and Instruction

IC Title:

Basic Health Plan State Report for Health Insurance Exchange Premiums

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10510	BHP State Report for Health Insurance Exchange Premiums	BHP State Report for Exchange Premiums 11-20-2013 final.xlsx		Yes	Yes	Fillable Printable
Other-PRA Disclosure Statement			BHP Disclosure Statement 11182013.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	17	17
Annual IC Time Burden (Hours)	68	68
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.