Essential Health Benefits Benchmark Plans

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10448 Notice of Intent to Provide Dental Coverage in the Exchange	Form and Instruction	Unchanged	Available
Form CMS-10448 EHB State Submission of State Mandates Template	Form and Instruction	Unchanged	Available
Form CMS-10448 EHB Benefits Template	Form and Instruction	Unchanged	Available
Form CMs-10448 Prescription Drug Formulary	Form and Instruction	Unchanged	Repair queued
Form CMS-10448 EHB Prescription Drug Template	Form and Instruction	Unchanged	Available
Form CMS-10448 State Mandate Template	Form and Instruction	Unchanged	Repair queued
Form CMS-10448 EHB Issuer Benchmark	Form and Instruction	Unchanged	Available
Form CMS-10448 EHB CMS State Benchmark	Form and Instruction	Unchanged	Available
CMS-10448 - EHB Supporting Statement 3315.docx	Supporting Statement A	Uploaded 2015-05-27	Available
StateBenchmark PRA amendment 2-5-13.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2013-02-20	Available
Appendix_B_EHB_Elements 08-14-2012.docx	Supplementary Document	Uploaded 2012-08-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
203740	EHB Dental Plan Issuers	Form and Instruction	Unchanged	Notice of Intent to Provide Dental Coverage in the Exchange
203739	Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Form and Instruction	Unchanged	EHB State Submission of State Mandates Template
203739	Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Form and Instruction	Unchanged	EHB Benefits Template
203739	Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Form and Instruction	Unchanged	Prescription Drug Formulary
203739	Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Form and Instruction	Unchanged	EHB Prescription Drug Template
203739	Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Form and Instruction	Unchanged	State Mandate Template
203739	Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Form and Instruction	Unchanged	EHB Issuer Benchmark
203739	Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Form and Instruction	Unchanged	EHB CMS State Benchmark
203739	Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	Instruction	Unchanged

ICR Details

OMB Control No: 0938-1174	ICR Reference No: 201505-0938-012
Status: Historical Inactive	Previous ICR Reference No: 201303-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No: 18885
Title: Essential Health Benefits Benchmark Plans
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 08/14/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/29/2015
Terms of Clearance: Withdrawn at agency's request

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	36 Months From Approved	09/30/2015
Responses	178	0	178
Time Burden (Hours)	642	0	642
Cost Burden (Dollars)	0	0	0

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Abstract: The Affordable Care Act requires that all qualified health plans (QHPs) offered in the Exchanges provide the essential health benefits (EHB) and be accredited by an accrediting entity that is recognized by the Secretary of Health and Human Services. In order to establish EHB benchmark plans in each State, CMS will collect data from potential default benchmark plan issuers in each State and from States that select their own benchmark. CMS also intends to ask all States for a voluntary submission of their State mandated benefits. This data collection will include: administrative data necessary to identify the plan, all health benefits offered by the plans and associated limits, drug coverage, network type, and plan level enrollment. Finally, we plan to collect submissions from dental plan issuers on whether they intend to apply for certification to participate in the Exchanges as stand-alone plans.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1201, 1301, 1302, 1311, 1321 Name of Law: Patient Protection and Affordable Care Act (Affordable Care Act)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AS19	Final or interim final rulemaking	80 FR 10749	02/27/2015

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 70674	11/26/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 10749	02/27/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
EHB Dental Plan Issuers	CMS-10448	Notice of Intent to Provide Dental Coverage in the Exchange
Essential Health Benefits Benchmark Plans and Accrediting Entities Data Collection	CMS-10448, CMS-10448, CMS-10448, CMS-10448, CMs-10448, CMS-10448, CMS-10448	EHB CMS State Benchmark ,   EHB Issuer Benchmark ,   State Mandate Template ,   EHB Prescription Drug Template ,   Prescription Drug Formulary ,   EHB Benefits Template ,   EHB State Submission of State Mandates Template

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/29/2015

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