Information Collection

Issuers - Submission Preparation (Small Group)

IC 199278 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⚠️ Notice: This information collection may be referencing outdated material.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 Issuers - Submission Preparation (Small Group)	Form and Instruction
CMS 10320 Appendix C Issuer and Product Level Data_PRA 2020.pdf	Instruction
CMS 10320 Appendix C Issuer and Product Level Data_PRA 2020.pdf	Instruction
CMS 10320 Appendix D_Data Collection_PRA2020.pdf	Instruction
CMS 10320 Appendix D_Data Collection_PRA2020.pdf	Instruction
CMS-10320 Issuer Instructions and Instruments CMS-10320 Issuer - FINAL Instructions and Instruments.pdf	Form and Instruction
CMS-10320 Issuer Instructions and Instruments CMS-10320 Issuer - FINAL Instructions and Instruments.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

IC Title:

Issuers - Submission Preparation (Small Group)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10320	Issuer Instructions and Instruments	CMS-10320 Issuer - FINAL Instructions and Instruments.pdf	Yes	Yes	Fillable Fileable
Instruction			CMS 10320 Appendix C Issuer and Product Level Data_PRA 2020.pdf	Yes	Yes	Paper Only
Instruction			CMS 10320 Appendix D_Data Collection_PRA2020.pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	500	-200	700
Annual IC Time Burden (Hours)	26,000	-4,800	30,800
Annual IC Cost Burden (Dollars)	0	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

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