QHP Certification

Initial Plan Data Collection to Support QHP Certification and other Financial Management and Exchange Operations (CMS-10433)

OMB: 0938-1187

IC ID: 206068

Documents and Forms

Document Name Document Type
Form CMS-10433 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