Crosswalk of changes document

Tracking for Changes to the PRA Template
• Updated: each Excel Template worksheet was broken up into seprarate workbooks
• Updated: all Templates to Align with the Policy in the Final Rule
• Removed: “no” for “orthodontia-child under summary of benefits
• Removed: column “C” from States’ EHB Confirmation
• Added: “Alternate” to the contact list under “States’ EHB Confirmation
• Changed: Row “A10” is lighter so State can complete the information under “States’ EHB Confirmation.
• Significantly changed: reflect the policy in the final rule, added footnotes, add space for responses
• Changed: reflect the policy final rule for actuarial certification and associated Yes/No
• Updated: cell A12 to reference §156.111(a)(1) instead of Option 1
• Updated: cells A29, A30, A31 and A32 were adjusted to reflect policy finalized the final 2019 Payment Notice
• Changed: Drop-down options and updated associated call information for A11, A30, A31, A32, A 34, A38 and A39 to align with final policy

Which Template
All
All
EHB Chart
State Confirmations
States' EHB Confirmation
States' EHB Confirmation
Actuarial Cert
EHB Document Chart
State Confirmations
State Confirmations
State Confirmations

PRA Disclosure Statement
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 0938-1174. The time required to complete this information collection is estimated to average 47 hours or 2,820 minutes per response for States and .5 hours or 30 minutes per response
for Stand Alone Dental Plans. This time includes preparing, reviewing and submitting required documents. 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.

OMB Control Number: 0938-1174
Expiration Date: XX/XX/2021