EHB Substitution

Essential Health Benefits Benchmark Plans (CMS-10448)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1174 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10448 EHB Substitution Form and Instruction
CMS-10488 Substitution Notification AppF-State-Sub-Notif-508.pdf Form and Instruction
CMS-10448 State Documentation Requirements AppE-EHB-Chart.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	EHB Substitution	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156.115

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10448	State Documentation Requirements	AppE-EHB-Chart.pdf		Yes	Yes	Paper Only
Form and Instruction	CMS-10488	Substitution Notification	AppF-State-Sub-Notif-508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.