Non-Standardized Plan Option Limit Exceptions

Non-Standardized Plan Option Limit Exception Justification Form (CMS-10878)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1461 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10878 Non-Standardized Plan Option Limit Exceptions Form and Instruction
CMS-10878 Non-Standardized Plan Option Limit Exceptions CMS-10878 - NSPO_Appendix_A_Justification_Form.pdf Form and Instruction
CMS-10878 Non-Standardized Plan Option Limit Exceptions CMS-10878 - NSPO_Appendix_A_Justification_Form.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Non-Standardized Plan Option Limit Exceptions	Agency IC Tracking Number:	CCIIO - 10878

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156.202

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10878	Non-Standardized Plan Option Limit Exceptions	CMS-10878 - NSPO_Appendix_A_Justification_Form.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	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 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	27,400	27,400

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.