Information Collection

Basic Health Plan State Report for Health Insurance Exchange Premiums

IC 209843 under ICR 201406-0938-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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
BHP Disclosure Statement 11182013.doc	Other-PRA Disclosure Statement
CMS-10510 BHP State Report for Exchnage Premiums Copy of BHP State Report for Exchange Premiums 4-7-2014.pdf	Form and Instruction
Crosswalk 4 7 2014 (rev 6-27-2014 by OSORA PRA).xlsx Crosswalk	IC Document

IC Title:

Basic Health Plan State Report for Health Insurance Exchange Premiums

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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
Other-PRA Disclosure Statement			BHP Disclosure Statement 11182013.doc		Yes	No	Printable Only
Form and Instruction	CMS-10510	BHP State Report for Exchnage Premiums	Copy of BHP State Report for Exchange Premiums 4-7-2014.pdf		Yes	Yes	Fillable Printable

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	Previously Approved
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
Crosswalk	Crosswalk 4 7 2014 (rev 6-27-2014 by OSORA PRA).xlsx	06/27/2014

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