Basic Health Program Supporting Regulations

Basic Health Program Report for Health Insurance Exchange Premium (CMS-10510)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1218 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10510 Basic Health Program Supporting Regulations Form and Instruction
Actual Enrollment Data Sample Spreadsheet.xlsx Instruction
Actual Enrollment Data Sample Spreadsheet.xlsx Instruction
CMS-10510 Annual Report 2022 Annual Report Template for BHP Final (2022 version 2).docx Form and Instruction
CMS-10510 Annual Report 2022 Annual Report Template for BHP Final (2022 version 4).docx Form and Instruction
CMS-10510 Blueprint Blueprint Template (2022 version 2).docx Form and Instruction
CMS-10510 Blueprint Blueprint Template (2022 version 4).docx Form and Instruction
CMS-10510 State Report for Health Insurance Exchange Premiums State Report for Exchange Premiums (2022 version 2).xlsx Form and Instruction
CMS-10510 State Report for Health Insurance Exchange Premiums State Report for Exchange Premiums (2022 version 2).xlsx Form and Instruction
CMS-10510 Enrollment Data Guide 508EnrollDataGuideNov2015.pdf Form and Instruction
CMS-10510 Enrollment Data Guide 508EnrollDataGuideNov2015.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Basic Health Program Supporting Regulations	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10510	Annual Report	2022 Annual Report Template for BHP Final (2022 version 4).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10510	Blueprint	Blueprint Template (2022 version 4).docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10510	State Report for Health Insurance Exchange Premiums	State Report for Exchange Premiums (2022 version 2).xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10510	Enrollment Data Guide	508EnrollDataGuideNov2015.pdf	Yes	Yes	Fillable Fileable
Instruction			Actual Enrollment Data Sample Spreadsheet.xlsx	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Health Insurance Exchanges (HIX) Program	FR Citation: 78 FR 63211

Number of Respondents: 2	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	27	27
Annual IC Time Burden (Hours)	2,568	2,568
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.