Form CMS-10488 Substitution Notification

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

Appendix G – State Substitution Notification
Beginning a State Opt-in
1. Will your State allow EHB substitution between EHB categories (optional field)?
Yes
No

2. If yes, what plan year will the State begin allowing between EHB category substitution (optional field)?

Ending a State Opt-in
3. If the State has been allowing between EHB category substitution, check this box if the State
intends to terminate between EHB category substitution (optional field)?
Yes – terminate between EHB category substitution.
4. If yes, what plan year will the State begin terminating between EHB category substitution
(optional field)?

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 0938-1174. 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.