Information Collection

QHP Certification

IC 206068 under ICR 202204-0938-007 · OMB 0938-1187.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1187 can be found here:

2026-04-07 - Reinstatement without change of a previously approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10433 QHP Certification	Form and Instruction
CMS-10433 Administrative Data Template CMS-10433 - Appendix A-Accred-Admin-Screenshots.pdf	Form and Instruction
CMS-10433 Administrative Data Template CMS-10433 - Appendix A-Accred-Admin-Screenshots.pdf	Form and Instruction
CMS-10433 Plan Benefits Template C_Plan_ID_Crosswalk_Template.pdf	Form and Instruction
CMS-10433 Plan Benefits Template C_Plan_ID_Crosswalk_Template.pdf	Form and Instruction
CMS-10433 Network ID Template B_URL_Template.pdf	Form and Instruction
CMS-10433 Network ID Template B_URL_Template.pdf	Form and Instruction
CMS-10433 Plans and Benefits Template D_Plans_and_Benefits_Template.pdf	Form and Instruction
CMS-10433 Plans and Benefits Template D_Plans_and_Benefits_Template.pdf	Form and Instruction
CMS-10433 Prescriptions Drug Formulary Template E_Perscrption_Drug_Template.pdf	Form and Instruction
CMS-10433 Prescriptions Drug Formulary Template E_Perscrption_Drug_Template.pdf	Form and Instruction
CMS-10433 Rate Table Template AppG_NONFUNCTIONAL_RateTables.xls	Form and Instruction
CMS-10433 Rate Table Template AppG_NONFUNCTIONAL_RateTables.xls	Form and Instruction
CMS-10433 Service Area Template I_Service_Area_Template.pdf	Form and Instruction
CMS-10433 Service Area Template I_Service_Area_Template.pdf	Form and Instruction
CMs-10433 Business Rules Template H_Business_Rules_Template.pdf	Form and Instruction
CMs-10433 Business Rules Template H_Business_Rules_Template.pdf	Form and Instruction
CMS-10433 QHP Certification Instrument Screenshots J_Interoperability_Compliance_Web_ Form.pdf	Form and Instruction
CMS-10433 QHP Certification Instrument Screenshots J_Interoperability_Compliance_Web_ Form.pdf	Form and Instruction
CMS-10433 Reinsurance Program and Risk Adjustment Program F_RA_Programs_Payment_Ops_Data.pdf	Form and Instruction
CMS-10433 Reinsurance Program and Risk Adjustment Program F_RA_Programs_Payment_Ops_Data.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

QHP Certification

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 156.200 45 CFR 155.1065

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-10433	Administrative Data Template	CMS-10433 - Appendix A-Accred-Admin-Screenshots.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Plan Benefits Template	C_Plan_ID_Crosswalk_Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Network ID Template	B_URL_Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Plans and Benefits Template	D_Plans_and_Benefits_Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Prescriptions Drug Formulary Template	E_Perscrption_Drug_Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Rate Table Template	AppG_NONFUNCTIONAL_RateTables.xls	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Service Area Template	I_Service_Area_Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMs-10433	Business Rules Template	H_Business_Rules_Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	QHP Certification Instrument Screenshots	J_Interoperability_Compliance_Web_ Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Reinsurance Program and Risk Adjustment Program	F_RA_Programs_Payment_Ops_Data.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 215

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	215	15	200
Annual IC Time Burden (Hours)	42,140	2,940	39,200
Annual IC Cost Burden (Dollars)	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.