Information Collection

Simplified Actuarial Value Methodology Plan and Policy Report

IC 213296 under ICR 202405-0938-030 · OMB 0938-1266.

Documents and Forms

Document Name Document Type
Form CMS-10526 Simplified Actuarial Value Methodology Plan and Policy Report Form and Instruction
CMS-10526 CSR Reconciliation Data Elements CMS-10526 - CSR Recon PRA_Collection Elements 30d.docx Form and Instruction
CMS-10526 CSR Reconciliation Data Elements CMS-10526 - CSR Recon PRA_Collection Elements 30d.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Simplified Actuarial Value Methodology Plan and Policy Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.430(c)(4)(v)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10526	CSR Reconciliation Data Elements	CMS-10526 - CSR Recon PRA_Collection Elements 30d.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,029,950	2,029,950
Annual IC Time Burden (Hours)	2,250	2,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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