Information Collection

QHP Certification

IC 206068 under ICR 201902-0938-012 · OMB 0938-1187.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1187 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10433 Administrative Data Template QHP Certification	Form and Instruction
Form CMS-10433 Network Adequacy Template QHP Certification	Form and Instruction
Form CMS-10433 Plan Benefits Template QHP Certification	Form and Instruction
Form CMS-10433 Network ID Template QHP Certification	Form and Instruction
Form CMS-10433 Plans and Benefits Template QHP Certification	Form and Instruction
Form CMS-10433 Prescriptions Drug Formulary Template QHP Certification	Form and Instruction
Form CMS-10433 Rate Table Template QHP Certification	Form and Instruction
Form CMS-10433 Service Area Template QHP Certification	Form and Instruction
Form CMs-10433 Business Rules Template QHP Certification	Form and Instruction
Form CMS-10433 QHP Certification Instrument Screenshots QHP Certification	Form and Instruction
Form CMS-10433 Reinsurance Program and Risk Adjustment Program QHP Certification	Form and Instruction
CMS-10433 Administrative Data Template CMS-10433 - Appendix A-Accred-Admin-Screenshots.pdf	Form and Instruction
CMS-10433 Network Adequacy Template AppK_NONFUNCTIONAL_EcpNetworkAdequacyTemplate.xlsm	Form and Instruction
CMS-10433 Plan Benefits Template AppC_NONFUNCTIONAL_PlanCW-Template.xlsm	Form and Instruction
CMS-10433 Network ID Template AppB_NONFUNCTIONAL_Networka.xls	Form and Instruction
CMS-10433 Plans and Benefits Template AppD_NONFUNCTIONAL_PlansBenefits.xlsm	Form and Instruction
CMS-10433 Prescriptions Drug Formulary Template AppE_NONFUNCTIONAL_PrescriptionDrug.xls	Form and Instruction
CMS-10433 Rate Table Template AppG_NONFUNCTIONAL_RateTables.xls	Form and Instruction
CMS-10433 Service Area Template AppI_NONFUNCTIONAL_ServiceArea.xls	Form and Instruction
CMs-10433 Business Rules Template AppH_NONFUNCTIONAL_RatingBusinessRules.xls	Form and Instruction
CMS-10433 QHP Certification Instrument Screenshots CMS-10433 - AppJ -Transparency.pdf	Form and Instruction
CMS-10433 Reinsurance Program and Risk Adjustment Program CMS-10433 - Appendix F-RA-Programs-Payment-Ops-Data.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

QHP Certification

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 155.1065 45 CFR 156.200

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-10433	Administrative Data Template	CMS-10433 - Appendix A-Accred-Admin-Screenshots.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Network Adequacy Template	AppK_NONFUNCTIONAL_EcpNetworkAdequacyTemplate.xlsm	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Plan Benefits Template	AppC_NONFUNCTIONAL_PlanCW-Template.xlsm	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Network ID Template	AppB_NONFUNCTIONAL_Networka.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Plans and Benefits Template	AppD_NONFUNCTIONAL_PlansBenefits.xlsm	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Prescriptions Drug Formulary Template	AppE_NONFUNCTIONAL_PrescriptionDrug.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Rate Table Template	AppG_NONFUNCTIONAL_RateTables.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Service Area Template	AppI_NONFUNCTIONAL_ServiceArea.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMs-10433	Business Rules Template	AppH_NONFUNCTIONAL_RatingBusinessRules.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	QHP Certification Instrument Screenshots	CMS-10433 - AppJ -Transparency.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Reinsurance Program and Risk Adjustment Program	CMS-10433 - Appendix F-RA-Programs-Payment-Ops-Data.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	200	-500	700
Annual IC Time Burden (Hours)	39,200	-69,000	108,200
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.