Information Collection

QHP Certification

IC 206068 under ICR 201511-0938-013 · OMB 0938-1187.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1187 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10433 Administrative Data Template QHP Certification	Form and Instruction
Form CMS-10433 Network Adequacy Template QHP Certification	Form and Instruction
Form CMS-10433 NCQA Template QHP Certification	Form and Instruction
Form CMS-10433 Network ID Template QHP Certification	Form and Instruction
Form CMS-10433 Plans and Benefits Template QHP Certification	Form and Instruction
Form CMS-10433 Prescriptions Drug Formulary Template QHP Certification	Form and Instruction
Form CMS-10433 Rate Table Template QHP Certification	Form and Instruction
Form CMS-10433 Service Area Template QHP Certification	Form and Instruction
Form CMs-10433 Business Rules Template QHP Certification	Form and Instruction
Form CMS-10433 QHP Certification Instrument Screenshots QHP Certification	Form and Instruction
Form CMS-10433 Reinsurance Program and Risk Adjustment Program QHP Certification	Form and Instruction
CMS-10433 Administrative Data Template CMS-10433 - Appendix A Administrative Data_508.xlsx	Form and Instruction
CMS-10433 Network Adequacy Template CMS-10433 - Appendix B NA ECP_508.xlsb	Form and Instruction
CMS-10433 NCQA Template CMS-10433 - Appendix C NCQA_508.xlsx	Form and Instruction
CMS-10433 Network ID Template CMS-10433 - Appendix F Network ID_508.xlsx	Form and Instruction
CMS-10433 Plans and Benefits Template CMS-10433 - Appendix G Plans and Benefits_508.xlsx	Form and Instruction
CMS-10433 Prescriptions Drug Formulary Template CMS-10433 - Appendix H Prescription Drug_508.xlsx	Form and Instruction
CMS-10433 Rate Table Template CMS-10433 - Appendix I Rates Table_508.xlsx	Form and Instruction
CMS-10433 Service Area Template CMS-10433 - Appendix J Service Area_508.xlsx	Form and Instruction
CMs-10433 Business Rules Template CMS-10433 - Appendix K Business Rules_508.xlsx	Form and Instruction
CMS-10433 QHP Certification Instrument Screenshots CMS-10433 - Appendix L QHP Certification Instrument Screenshots_10262015.pdf	Form and Instruction
CMS-10433 Reinsurance Program and Risk Adjustment Program CMS-10433 - Appendix M RI RA Programs and Payment Ops Data Requirements.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

QHP Certification

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.1065 45 CFR 156.200

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10433	Administrative Data Template	CMS-10433 - Appendix A Administrative Data_508.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Network Adequacy Template	CMS-10433 - Appendix B NA ECP_508.xlsb	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	NCQA Template	CMS-10433 - Appendix C NCQA_508.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Network ID Template	CMS-10433 - Appendix F Network ID_508.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Plans and Benefits Template	CMS-10433 - Appendix G Plans and Benefits_508.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Prescriptions Drug Formulary Template	CMS-10433 - Appendix H Prescription Drug_508.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Rate Table Template	CMS-10433 - Appendix I Rates Table_508.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Service Area Template	CMS-10433 - Appendix J Service Area_508.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMs-10433	Business Rules Template	CMS-10433 - Appendix K Business Rules_508.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	QHP Certification Instrument Screenshots	CMS-10433 - Appendix L QHP Certification Instrument Screenshots_10262015.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Reinsurance Program and Risk Adjustment Program	CMS-10433 - Appendix M RI RA Programs and Payment Ops Data Requirements.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 700

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: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	700	-275	975
Annual IC Time Burden (Hours)	108,200	-74,125	182,325
Annual IC Cost Burden (Dollars)	0	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.