CMS-10488 Substitution Notification

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

OMB No. 0938-1174

Expires: XX/XX/XXXX

ESSENTIAL HEALTH BENEFITS (EHB) 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” to question 1, what plan year will the State begin allowing substitutions between EHB categories (optional field)?

3. If “Yes” to question 1, between which EHB category or categories will the State allow substitutions? Note that
prescription drug substitutions are not allowed.
Ambulatory patient services

Rehabilitative and habilitative services
and devices

Emergency services

Laboratory services

Hospitalization

Preventive and wellness services and
chronic disease management

Maternity and newborn care

Pediatric services, including oral and
vision care

Mental health and substance
use disorder services including
behavioral health treatment

ENDING A STATE OPT-IN
4. 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

5. If yes to question 4, what plan year will the State begin terminating between EHB category substitution (optional
field)?

APPENDIX F: EHB STATE SUBSTITUTION NOTIFICATION

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

OMB No. 0938-1174

Expires: XX/XX/XXXX

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
XX/XX/XXXX). 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 F: EHB STATE SUBSTITUTION NOTIFICATION

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