Information Collection

Confirmations on the State EHB-benchmark Plan

IC 203740 under ICR 202408-0938-009 · OMB 0938-1174.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10448 Confirmations on the State EHB-benchmark Plan	Form and Instruction
CMS-10448 EHB State Confirmations CMS-10448_Appendix_A_EHB_State_Confirmations_508.pdf	Form and Instruction
CMS-10448 EHB State Confirmations CMS-10448_Appendix_A_EHB_State_Confirmations_508.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.111(e)(1)

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
Form and Instruction	CMS-10448	EHB State Confirmations	CMS-10448_Appendix_A_EHB_State_Confirmations_508.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

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: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	5	-170	175
Annual IC Time Burden (Hours)	20	-68	88
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.