CMS-10448 State Certification Annual Report (SBRs)

OMB Control Number: 0938-1174
Expiration Date: 06/01/2021
State Certification of Annual Report on State-Required Benefits
Under §156.111(d), a state must notify HHS of any state-required benefits that are in addition to
the essential health benefits (EHB) identified under §155.170(a)(3) in accordance with
§156.111(f), which specifies the types of information states are required to submit to HHS by the
annual submission deadline in a form and manner specified by HHS.
If the state does not notify HHS of its state-required benefits that are in addition to EHB
described under § 155.170(a)(3) in accordance with paragraph §156.111(f), HHS will determine
which benefits are in addition to EHB for the applicable plan year in the State.
To satisfy the requirement at §156.111(f)(5), a state must submit a document to HHS by the
annual submission deadline in a form and manner specified by HHS that is signed by a state
official with authority to make the submission on behalf of the state certifying the accuracy of
the submission.
This State Certification of Annual Report on State-Required Benefits should be submitted as an
attachment to the state’s submission of the State Annual Report on State-Required Benefits, that
states are required to use to report the remainder of the types of information states are required to
submit to HHS to comply with §156.111(f).
By signing below, you are attesting you are the state official with authority to make the
submission required under §156.111(d) and (f) on behalf of the state and that you certify the
accuracy of the state’s submission in the State Annual Report on State-Required Benefits.
_________________________________________
State
__________________________________________
Printed Name of State Official

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-1174 (Expires 06/01/2021). The time required to complete this information collection is
estimated to average 30 hours or 1,800 minutes in the first year and 13 hours or 780 minutes annually in the
second and third year for states to report state mandates. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will not be
reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents,
please contact Valisha Jackson at [email protected].

OMB Control Number: 0938-1174
Expiration Date: 06/01/2021

___________________________________________
Printed Title of State Official
___________________________________________

_______________________

Signature of State Official

Date

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-1174 (Expires 06/01/2021). The time required to complete this information collection is
estimated to average 30 hours or 1,800 minutes in the first year and 13 hours or 780 minutes annually in the
second and third year for states to report state mandates. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will not be
reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents,
please contact Valisha Jackson at [email protected].