Information Collection

Simplified Actuarial Value Methodology Plan and Policy Report

IC 213296 under ICR 201703-0938-006 · OMB 0938-1266.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1266 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10526 Simplified Actuarial Value Methodology Plan and Policy Report	Form and Instruction
CMS-10526 CSR Reconciliation Data Elements CMS-10526 CSR Recon PRA_Collection Elementsx.docx	Form and Instruction

IC Title:

Simplified Actuarial Value Methodology Plan and Policy Report

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.430(c)(4)(v)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10526	CSR Reconciliation Data Elements	CMS-10526 CSR Recon PRA_Collection Elementsx.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 191

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,339,941	0	2,339,941
Annual IC Time Burden (Hours)	306	72	234
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.