QHP Certification

Initial Plan Data Collection to Support QHP Certification and other Financial Management and Exchange Operations (CMS-10433)

OMB: 0938-1187

IC ID: 206068

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

QHP Certification
 
No Modified
 
Required to Obtain or Retain Benefits
 
45 CFR 156.200 45 CFR 155.1065

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

215 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 215 0 0 15 0 200
Annual IC Time Burden (Hours) 42,140 0 0 2,940 0 39,200
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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