Appendix B

OMB Control # 0938-1284

Expiration Date: xx/xx/xxxx

Appendix B

PRA DISCLOSURE:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1284. The time required to complete this information collection is estimated to average 136 hours per response for new QHP issuers in the first year and 36 hours for returning QHP issuers in the first year, including the time to review instructions, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.