Information Collection

Web-broker Operational Readiness Reviews (ORR)

IC 263263 under ICR 202311-0938-002 · OMB 0938-1463.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1463 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10877 Web-broker Operational Readiness Reviews (ORR)	Form and Instruction
CMS-10877 Web-Broker Agreement CMS-10877 - Appendix_A_Web-broker_Agreement.pdf	Form and Instruction
CMS-10877 Web-Broker Agreement CMS-10877 - Appendix_A_Web-broker_Agreement.pdf	Form and Instruction
CMS-10877 Security and Privacy Assessment Reports (SARs) template CMS-10877 - Appendix_B_NEE-EDE-SAR-Template.pdf	Form and Instruction
CMS-10877 Security and Privacy Assessment Reports (SARs) template CMS-10877 - Appendix_B_NEE-EDE-SAR-Template.pdf	Form and Instruction
CMS-10877 Plans of Action and Milestones (POA&Ms) template CMS-10877 - Appendix_C_NEE-POA&M-Template.pdf	Form and Instruction
CMS-10877 Plans of Action and Milestones (POA&Ms) template CMS-10877 - Appendix_C_NEE-POA&M-Template.pdf	Form and Instruction
CMS-10877 System Security and Privacy Plans (SSPs) workbook CMS-10877 - Appendix_D_NEE-EDE-SSP-Workbook.pdf	Form and Instruction
CMS-10877 System Security and Privacy Plans (SSPs) workbook CMS-10877 - Appendix_D_NEE-EDE-SSP-Workbook.pdf	Form and Instruction

IC Title:

Web-broker Operational Readiness Reviews (ORR)

Agency IC Tracking Number:

CCIIO - 10877

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.205, 220-221 45 CFR 156.1230

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10877	Web-Broker Agreement	CMS-10877 - Appendix_A_Web-broker_Agreement.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10877	Security and Privacy Assessment Reports (SARs) template	CMS-10877 - Appendix_B_NEE-EDE-SAR-Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10877	Plans of Action and Milestones (POA&Ms) template	CMS-10877 - Appendix_C_NEE-POA&M-Template.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10877	System Security and Privacy Plans (SSPs) workbook	CMS-10877 - Appendix_D_NEE-EDE-SSP-Workbook.pdf	Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	380	380
Annual IC Cost Burden (Dollars)	27,786	27,786

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.