Information Collection

Individual - Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing andAppeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment

IC 207762 under ICR 201705-0938-014 · OMB 0938-1207.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1207 can be found here:

Documents and Forms

Document Name Document Type
CMS-10468 - Appendix A - Data Elements.docx Other-Data Elements

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Individual - Essential Health Benefits in Alternative Benefit Plans, Eligibility Notices, Fair Hearing andAppeal Processes, and Premiums and Cost Sharing; Exchanges: Eligibility and Enrollment	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 156 45 CFR 155 45 CFR 157

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Data Elements			CMS-10468 - Appendix A - Data Elements.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	18	18
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	1,134	1,134

Documents for IC

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.