Information Collection

States - Data submission

IC 192725 under ICR 202108-0938-007 · OMB 0938-1086.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1086 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10320 States - Data submission	Form and Instruction
CMS-10320 Appendix_E_StateRequirements.pdf	Instruction
CMS-10320 Appendix_E_StateRequirements.pdf	Instruction
CMS-10320 Health Care Reform Insurance Web Portal Requirements - S CMS-10320.FINAL State Instructions and Instrument.pdf	Form and Instruction
CMS-10320 Health Care Reform Insurance Web Portal Requirements - S CMS-10320.FINAL State Instructions and Instrument.pdf	Form and Instruction
CMS 10320 Appendix G_2020 .xlsm Data Collection Template	IC Document
CMS 10320 Appendix G_2020 .xlsm Data Collection Template	IC Document
CMS-10320 Appendix_F_PoolRequirements.2017_v2.pdf State Risk Pool	IC Document
CMS-10320 Appendix_F_PoolRequirements.2017_v2.pdf State Risk Pool	IC Document

IC Title:

States - Data submission

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10320	Health Care Reform Insurance Web Portal Requirements - State Instructions and Instrument	CMS-10320.FINAL State Instructions and Instrument.pdf		Yes	No	Fillable Fileable Signable
Instruction			CMS-10320 Appendix_E_StateRequirements.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Data Collection Template	CMS 10320 Appendix G_2020 .xlsm	01/28/2022
State Risk Pool	CMS-10320 Appendix_F_PoolRequirements.2017_v2.pdf	01/28/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.