Information Collection

Product Discontinuance Notice for QHP Issuers

IC 212939 under ICR 202304-0938-018 · OMB 0938-1254.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1254 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10527 Product Discontinuance Notice for QHP Issuers	Form and Instruction
CMS-10527 Discontinuation Notices CMS-10527 Attachment 4 - Discontinuation Notice with auto enrollment QHP.pdf	Form and Instruction
CMS-10527 Discontinuation Notices CMS-10527 Attachment 4 - Discontinuation Notice with auto enrollment QHP 30-day rev.pdf	Form and Instruction
CMS-10527 Discontinuation without auto enrollment (QHP) CMS-10527 Attachment 6 - Discontinuation Notice without auto enrollment QHP 30 - day clean.pdf	Form and Instruction
CMS-10527 Discontinuation without auto enrollment (QHP) CMS-10527 Attachment 6 - Discontinuation Notice without auto enrollment QHP 30 - day clean.pdf	Form and Instruction

IC Title:

Product Discontinuance Notice for QHP Issuers

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.1255 45 CFR 147.106

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-10527	Discontinuation Notices	CMS-10527 Attachment 4 - Discontinuation Notice with auto enrollment QHP 30-day rev.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10527	Discontinuation without auto enrollment (QHP)	CMS-10527 Attachment 6 - Discontinuation Notice without auto enrollment QHP 30 - day clean.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 333

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	666	178	488
Annual IC Time Burden (Hours)	4,829	1,291	3,538
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.