Information Collection Request

Initial Plan Data Collection to Support QHP Certification and other Financial Management and Exchange Operations

ICR 201409-0938-005 · OMB 0938-1187 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10433 Business Rules Form Modified Available
Form CMS-10433 Rates Table Form Modified Available
Form CMS-10433 Service Area Form Modified Available
Form CMS-10433 Prescription Drugs Template Form Modified Available
Form CMS-10433 Plan and Benefit Form Modified Available
Form CMS-10433 Accreditation Attestations Form Modified Available
Form CMS-10433 Program Attestations Form Modified Available
Form CMS-10433 Network Adequacy Form Modified Available
Form CMS-10433 AAAHC Form Modified Available
Form CMS-10433 NCQA Template Form Modified Available
Form CMS-10433 URAC Application Form Modified Available
Form CMS-10433 Dental Essential Community Provider Form Modified Available
Form CMS-10433 Medical Essential Community Providers Form Modified Available
Form CMS-10433 Data Template Administrative Form Modified Available
Form CMS-10433 Network ID Form Modified Available
CMS-10433 - Emergency Justification (7-8-14).docx Supplementary Document Uploaded 2014-09-11 Available
CMS-10433 - QHP Edge Server Supporting Statement Emergency (9-10-14) v2clean.docx Supporting Statement A Uploaded 2014-09-11 Available
CMS-10433_Edge PRA summary comment.docx Supplementary Document Uploaded 2014-09-11 Available
CMS-10433 QHP Template Changes Overview for OSORA 4-15-14.docx Supplementary Document Uploaded 2014-04-15 Available
FINAL QHP PRA Comments-Responses 1.29.14.xlsx Supplementary Document Uploaded 2014-02-10 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
206071 States Unchanged
206070 Reinsurance Instruction Modified
206069 Reinsurance and Risk Adjustment Instruction Modified
206068 QHP Certification Instruction Modified
206068 QHP Certification Form ModifiedBusiness Rules
206068 QHP Certification Form ModifiedRates Table
206068 QHP Certification Form ModifiedService Area
206068 QHP Certification Form ModifiedPrescription Drugs Template
206068 QHP Certification Form ModifiedPlan and Benefit
206068 QHP Certification Form ModifiedAccreditation Attestations
206068 QHP Certification Form ModifiedProgram Attestations
206068 QHP Certification Form ModifiedNetwork Adequacy
206068 QHP Certification Form ModifiedAAAHC
206068 QHP Certification Form ModifiedNCQA Template
206068 QHP Certification Form ModifiedURAC Application
206068 QHP Certification Form ModifiedDental Essential Community Provider
206068 QHP Certification Form ModifiedMedical Essential Community Providers
206068 QHP Certification Form ModifiedData Template Administrative
206068 QHP Certification Form ModifiedNetwork ID

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
04/30/2015 6 Months From Approved 04/30/2017
27,225 0 27,225
317,275 0 316,675
0 0 0





Reginfo record details
4
table that charts list of burden
IC Title Form No. Form Name
QHP Certification CMS-10433, CMS-10433, CMS-10433, CMS-10433, CMS-10433, CMS-10433, CMS-10433, CMS-10433, CMS-10433, CMS-10433, CMS-10433, CMS-10433, CMS-10433, CMS-10433, CMS-10433 ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,  
Reinsurance
Reinsurance and Risk Adjustment
States

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 27,225 27,225 0 0 0 0
Annual Time Burden (Hours) 317,275 316,675 0 600 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No