Information Collection

Disclosure of State Rating Requirements

IC 208568 under ICR 201802-0938-003 · OMB 0938-1258.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1258 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10454 Disclosure of State Rating Requirements	Form and Instruction
CMS-10454 State Rating Requirements Disclosure Form CMS-10454 - State Rating Requirements Disclosure Form 2016.docx	Form and Instruction

IC Title:

Disclosure of State Rating Requirements

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 147.102

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-10454	State Rating Requirements Disclosure Form	CMS-10454 - State Rating Requirements Disclosure Form 2016.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 47

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	423	-9	432
Annual IC Time Burden (Hours)	2,338	254	2,084
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.