EHB Reporting

Essential Health Benefits Benchmark Plans (CMS-10448)

OMB: 0938-1174

IC ID: 229047

Information Collection (IC) Details

View Information Collection (IC)

EHB Reporting
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 156.111(e)(1)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10488 EHB Confirmation Template CMS-10448_ Appendix A EHB BM Plans 2019_State EHB Confirmation Template.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10448 EHB Benchmark Plan Certification CMS-10448_ Appendix B EHB Benchmark Plan Cert.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10448 Benchmark Plans Prescription Template CMS-10448_ Appendix D EHB BM Plans_Rx Template.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10448 Summary of Benefits Template CMS-10448_ Appendix C EHB BM Plans 2019_Summary of Benefits Template.pdf Yes No Paper Only

Health Health Care Services

 

10 0
   
State, Local, and Tribal Governments
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 400 10 0 390 0 0
Annual IC Time Burden (Hours) 470 399 0 71 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Appendix E - Benchmark Plans 2019 EHB Chart - Information Only CMS-10448_ Appendix E EHB BM Plans 2019_EHB Chart.pdf 04/17/2018
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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