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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10433 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:

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

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 %

	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

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.