Information Collection Requirements for Compliance with Individual and Group Market Reforms under Title XXVII of the Public Health Service Act

Information Collection Requirements Referenced in HIPAA for the Group Market, Supporting Regulations 45 CFR 146, and forms/instructions

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0702 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10430 Information Collection Requirements for Compliance with Individual and Group Market Reforms under Title XXVII of the Public Health Service Act Form and Instruction
CMS-10430 Model_Election_Exemption CMS-10430_Model_Election_Exemption.pdf Form and Instruction
CMS-10430 Model_Notice_to_Enrollees CMS-10430_Model_Notice_to_Enrollees.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Information Collection Requirements for Compliance with Individual and Group Market Reforms under Title XXVII of the Public Health Service Act	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 146.111 45 CFR 146.115 45 CFR 146.117 45 CFR 146.150 45 CFR 146.152 45 CFR 146.160 45 CFR 146.180

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10430	Model_Notice_to_Enrollees	CMS-10430_Model_Notice_to_Enrollees.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-10430	Model_Election_Exemption	CMS-10430_Model_Election_Exemption.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,800	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: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	39,831,442	39,831,442
Annual IC Time Burden (Hours)	3,760,421	3,760,421
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.