Risk Adjustment

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

Documents and Forms

Document Name Document Type
Form CMS-10433 Risk Adjustment Form and Instruction
CMS-10433 Reinsurance and Risk Adjustment Bank Server CMS-10433 - Appendix M RI RA Programs and Payment Ops Data Requirements.pdf Form and Instruction
CMS-10433 Reinsurance and Risk Adjustment Bank Server CMS-10433 - Appendix M RI RA Programs and Payment Ops Data Requirements.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Risk Adjustment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 153.220, 410, 540, 610

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10433	Reinsurance and Risk Adjustment Bank Server	CMS-10433 - Appendix M RI RA Programs and Payment Ops Data Requirements.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,400	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	7,800	7,800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.