Form CMS-10448 State Documentation Requirements

Overview of State Documentation Requirements for EHBbenchmark Plans

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

The below chart provides an overview of the documents that a State needs to submit when selecting an EHB-benchmark Plan. These documents vary based on which option the State is using to
select for its EHB-benchmark Plan.

State Documentation Requirements

Confirmations: Complies with §156.111(a),
(b), and (c)
Actuarial certification and report:
1) Equal to, greater than, the scope of
benefits provided under a typical employer
plan
2) Does not exceed the generosity of the
most generous among certain plans
State’s EHB-benchmark plan document:
1) Describes benefits and limits in
accordance with §156.111(e)(3)
2) Provides formulary drug list for the
State's EHB-benchmark Plan
EHB Summary Chart: Provides a summary
of the State's EHB-benchmark Plan

Option 2: Replace category or
Option 1: Select another
categories of benefits from
State's EHB-benchmark Plan [in
another State’s EHB-benchmark
accordance with
Plan [in accordance with §
§156.111(a)(1)]
156.111(a)(2)]
Required?
Required?

Option 3: Otherwise select a set of
benefits for the State’s EHBbenchmark Plan [in accordance with
§156.111(a)(3)]

Does this document require use of a
specific template?

Required?

Required?

Yes

Yes

Yes

Yes

Yes

Yes

Yes

For the certification, yes;
For the report, no

Yes

Yes

Yes

For the certification, yes;
For the report, no

Yes

Yes

Yes

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

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].