Form CMS-10488 Substitution Notification

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-1174

Expires: 06/01/2021

APPENDIX G: STATE SUBSTITUTION NOTIFICATION
BEGINNING A STATE OPT-IN
1. Will your State allow EHB substitution between EHB categories (optional field)?

Yes
No
2. If yes, what plan year will the State begin allowing between EHB category substitution (optional field)?

ENDING A STATE OPT-IN
3. If the State has been allowing between EHB category substitution, check this box if the State intends to terminate
between EHB category substitution (optional field)?
Yes – terminate between EHB category substitution.
4. If yes, what plan year will the State begin terminating between EHB category substitution (optional field)?

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 47 hours or 2,820 minutes per
response for States. For Form 1, the estimate is 4 hours. For Form 2, the estimate is 19 hours. For Form 3, the estimate is 12
hours. For Form 4, the estimate is 12 hours. 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].
APPENDIX G: STATE SUBSTITUTION NOTIFICATION

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