Information Collection

Risk Adjustment

IC 206069 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⚠️ Notice: This information collection may be referencing outdated material.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 Risk Adjustment	Form and Instruction
CMS-10433 Reinsurance and Risk Adjustment Bank Server CMS-10433 - Appendix M RI RA Programs and Payment Ops Data Requirements.pdf	Form and Instruction

IC Title:

Risk Adjustment

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 153.220, 410, 540, 610

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10433	Reinsurance and Risk Adjustment Bank Server	CMS-10433 - Appendix M RI RA Programs and Payment Ops Data Requirements.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,400

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	Previously Approved
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	7,800	7,800
Annual IC Cost Burden (Dollars)	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.