Information Collection

Basic Health Program Supporting Regulations

IC 209843 under ICR 202311-0938-008 · OMB 0938-1218.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10510 Basic Health Program Supporting Regulations	Form and Instruction
Actual Enrollment Data Sample Spreadsheet.xlsx	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 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 Enrollment Data Guide 508EnrollDataGuideNov2015.pdf	Form and Instruction

IC Title:

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:

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-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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	47	20	27
Annual IC Time Burden (Hours)	3,172	604	2,568
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.