Information Collection

EHB Reporting

IC 229047 under ICR 201804-0938-010 · OMB 0938-1174.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1174 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10488 EHB Reporting	Form and Instruction
CMS-10488 EHB Confirmation Template CMS-10448_ Appendix A EHB BM Plans 2019_State EHB Confirmation Template.pdf	Form and Instruction
CMS-10448 EHB Benchmark Plan Certification CMS-10448_ Appendix B EHB Benchmark Plan Cert.pdf	Form and Instruction
CMS-10448 Benchmark Plans Prescription Template CMS-10448_ Appendix D EHB BM Plans_Rx Template.pdf	Form and Instruction
CMS-10448 Summary of Benefits Template CMS-10448_ Appendix C EHB BM Plans 2019_Summary of Benefits Template.pdf	Form and Instruction
CMS-10448_ Appendix E EHB BM Plans 2019_EHB Chart.pdf Appendix E - Benchmark Plans 2019 EHB Chart - Information Only	IC Document

IC Title:

EHB Reporting

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 156.111(e)(1)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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

Documents for IC

table that charts IC Documents
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.