Information Collection

Direct Enrollment Entity Separate Plan Display Exception Requirement

IC 263333 under ICR 202404-0938-015 · OMB 0938-1463.

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IC Title:

Direct Enrollment Entity Separate Plan Display Exception Requirement

Agency IC Tracking Number:

CCIIO - 10877

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.221(c)(1)-(2)

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

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
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	32,016	32,016

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