Information Collection

Information Collection Requirements for Compliance with Individual and Group Market Reforms under Title XXVII of the Public Health Service Act

IC 43664 under ICR 202210-0938-005 · OMB 0938-0702.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0702 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10430 Information Collection Requirements for Compliance with Individual and Group Market Reforms under Title XXVII of the Public Health Service Act	Form and Instruction
CMS-10430 Model Notice to Enrollees CMS-10430_Model_Notice_to_Enrollees.pdf	Form and Instruction
CMS-10430 Model Notice to Enrollees CMS-10430_Model_Notice_to_Enrollees.pdf	Form and Instruction

IC Title:

Information Collection Requirements for Compliance with Individual and Group Market Reforms under Title XXVII of the Public Health Service Act

Agency IC Tracking Number:

CCIIO-10430

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 146.152 45 CFR 146.117 45 CFR 146.150 45 CFR 146.111 45 CFR 146.180 45 CFR 146.160 45 CFR 146.115

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10430	Model Notice to Enrollees	CMS-10430_Model_Notice_to_Enrollees.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 794

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: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	51,385	9,265	42,120
Annual IC Time Burden (Hours)	1,786	65	1,721
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.