QHP Network and Formulary - Developer Documentation

Information Collection for Machine Readable Data for Provider Network and Prescription Formulary Content for FFM QHPs (CMS-10558)

Documents and Forms

Document Name Document Type
Form CMS-10558 QHP Network and Formulary - Developer Documentation Form and Instruction
CMS-10558 Schema Screenshots CMS-10558_Machine_Readable_Appendix_A_Schema_Screenshots_508_09.29.23.pdf Form and Instruction
CMS-10558 Schema Screenshots CMS-10558_Machine_Readable_Appendix_A_Schema_Screenshots.pdf Form and Instruction
CMS-10558_Machine_Readable_Appendix_B_Issuer_Details_MPMS_Screenshots_508_10.04.23.pdf Appendix B IC Document
CMS-10558_Machine_Readable_Appendix_B_Issuer_Details_MPMS_Screenshots.pdf Appendix B - Issuer Details MPMS Screenshots IC Document

Information Collection (IC) Details

IC Title:	QHP Network and Formulary - Developer Documentation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.230(c) 45 CFR 156.122(d)(1)(2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10558	Schema Screenshots	CMS-10558_Machine_Readable_Appendix_A_Schema_Screenshots.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 434	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: 50 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,208	696	4,512
Annual IC Time Burden (Hours)	39,126	7,642	31,484
Annual IC Cost Burden (Dollars)	3,474,257	3,474,257	0

Documents for IC

Title	Document	Date Uploaded
Appendix B - Issuer Details MPMS Screenshots	CMS-10558_Machine_Readable_Appendix_B_Issuer_Details_MPMS_Screenshots.pdf	08/07/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.