Information Collection

EHB Reporting - EHB Actuarial Certificate Template

IC 229047 under ICR 202408-0938-009 · OMB 0938-1174.

Documents and Forms

Document Name Document Type
Form CMS-10488 EHB Reporting - EHB Actuarial Certificate Template Form and Instruction
CMS-10488 EHB Confirmation Template CMS-10448_Appendix_A_EHB_State_Confirmations_508.pdf Form and Instruction
CMS-10488 EHB Confirmation Template CMS-10448_Appendix_A_EHB_State_Confirmations_508.pdf Form and Instruction
CMS-10448 EHB Benchmark Plan Certification CMS-10448_Appendix_B_EHB_Benchmark_Plan_Certificate_508.pdf Form and Instruction
CMS-10448 EHB Benchmark Plan Certification CMS-10448_Appendix_B_EHB_Benchmark_Plan_Certificate_508.pdf Form and Instruction
CMS-10448 Benchmark Plans Prescription Template CMS-10448_Appendix_D_EHB_Benchmark_Plan_Rx_508.pdf Form and Instruction
CMS-10448 Benchmark Plans Prescription Template CMS-10448_Appendix_D_EHB_Benchmark_Plan_Rx_508.pdf Form and Instruction
CMS-10448 Summary of Benefits Template CMS-10448_Appendix_C_EHB_Summary_Benefits_508.pdf Form and Instruction
CMS-10448 Summary of Benefits Template CMS-10448_Appendix_C_EHB_Summary_Benefits_508.pdf Form and Instruction
CMS-10448 EHB Benchmark Plan Certificate CMS-10448_Appendix_B_EHB_Benchmark_Plan_Certificate_508.pdf Form and Instruction
CMS-10448 EHB Benchmark Plan Certificate CMS-10448_Appendix_B_EHB_Benchmark_Plan_Certificate_508.pdf Form and Instruction
CMS-10448_ Appendix E EHB BM Plans 2019_EHB Chart.pdf Appendix E - Benchmark Plans 2019 EHB Chart - Information Only IC Document
CMS-10448_ Appendix E EHB BM Plans 2019_EHB Chart.pdf Appendix E - Benchmark Plans 2019 EHB Chart - Information Only IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	EHB Reporting - EHB Actuarial Certificate Template	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 156.111(e)(2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10488	EHB Confirmation Template	CMS-10448_Appendix_A_EHB_State_Confirmations_508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	EHB Benchmark Plan Certification	CMS-10448_Appendix_B_EHB_Benchmark_Plan_Certificate_508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	Benchmark Plans Prescription Template	CMS-10448_Appendix_D_EHB_Benchmark_Plan_Rx_508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10448	Summary of Benefits Template	CMS-10448_Appendix_C_EHB_Summary_Benefits_508.pdf	Yes	No	Paper Only
Form and Instruction	CMS-10448	EHB Benchmark Plan Certificate	CMS-10448_Appendix_B_EHB_Benchmark_Plan_Certificate_508.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	5	-5	10
Annual IC Time Burden (Hours)	65	18	47
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix E - Benchmark Plans 2019 EHB Chart - Information Only	CMS-10448_ Appendix E EHB BM Plans 2019_EHB Chart.pdf	04/17/2018

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