Information Collection

Annual Submission of Transparency in Coverage Data

IC 221316 under ICR 202111-0938-008 · OMB 0938-1310.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1310 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10572 Annual Submission of Transparency in Coverage Data	Form and Instruction
CMS-10572 QHP Issuer Data Collection - Appendix A2 CMS-10572_Transparency in Coverage_Appendix A2.pdf	Form and Instruction
CMS-10572 QHP Issuer Data Collection - Appendix A2 CMS-10572_Transparency in Coverage_Appendix A2.pdf	Form and Instruction
CMS-10572 Data Submission Template - Appendix C CMS-10572_Transparency in Coverage_Appendix C.pdf	Form and Instruction
CMS-10572 Data Submission Template - Appendix C CMS-10572_Transparency in Coverage_Appendix C.pdf	Form and Instruction
CMS-10572 Data Elements - Appendix A1 CMS-10572_Transparency in Coverage_Apppendix A1.pdf	Form and Instruction
CMS-10572 Data Elements - Appendix A1 CMS-10572_Transparency in Coverage_Apppendix A1.pdf	Form and Instruction
CMS-10572 Data Templates Appendix B CMS-10572_Transparency in Coverage_Appendix B1.pdf	Form and Instruction
CMS-10572 Data Templates Appendix B CMS-10572_Transparency in Coverage_Appendix B1.pdf	Form and Instruction
CMS-10572 Data Template Appendix B2 CMS-10572_Transparency in Coverage_Appendix B2.pdf	Form and Instruction
CMS-10572 Data Template Appendix B2 CMS-10572_Transparency in Coverage_Appendix B2.pdf	Form and Instruction
CMS-10572 Data Template - Appendix D CMS-10572_Transparency in Coverage_Appendix D.pdf	Form and Instruction
CMS-10572 Data Template - Appendix D CMS-10572_Transparency in Coverage_Appendix D.pdf	Form and Instruction

IC Title:

Annual Submission of Transparency in Coverage Data

Agency IC Tracking Number:

10572

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.220 45 CFR 156.20

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-10572	QHP Issuer Data Collection - Appendix A2	CMS-10572_Transparency in Coverage_Appendix A2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Submission Template - Appendix C	CMS-10572_Transparency in Coverage_Appendix C.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Elements - Appendix A1	CMS-10572_Transparency in Coverage_Apppendix A1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Templates Appendix B	CMS-10572_Transparency in Coverage_Appendix B1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Template Appendix B2	CMS-10572_Transparency in Coverage_Appendix B2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Template - Appendix D	CMS-10572_Transparency in Coverage_Appendix D.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 360

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	360	0	-110	470
Annual IC Time Burden (Hours)	51,480	1,178	50,260	42
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
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.