Information Collection

Information Collection Requirements for Compliance with Individual and Group Market Reforms under Title XXVII of the Public Health Service Act

IC 43664 under ICR 202409-0938-012 · OMB 0938-0702.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0702 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CMS-10430_Model_Notice_to_Enrollees_ENGLISH.docx	Other-Notice
CMS-10430_Model_Notice_to_Enrollees_ARABIC.docx	Other-Notice
CMS-10430_Model_Notice_to_Enrollees_FRENCH.docx	Other-Notice
CMS-10430_Model_Notice_to_Enrollees_KOREAN.docx	Other-Notice
CMS-10430_Model_Notice_to_Enrollees_SPANISH.docx	Other-Notice
CMS-10430_Model_Notice_to_Enrollees_TAGALOG.docx	Other-Notice
CMS-10430_Model_Notice_to_Enrollees_TCHINESE.docx	Other-Notice
CMS-10430_Model_Notice_to_Enrollees_VIETNAMESE.docx	Other-Notice

IC Title:

Information Collection Requirements for Compliance with Individual and Group Market Reforms under Title XXVII of the Public Health Service Act

Agency IC Tracking Number:

CCIIO-10430

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 146.117 45 CFR 146.150 45 CFR 146.111 45 CFR 146.152 45 CFR 146.180 45 CFR 146.160 45 CFR 146.115

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Notice	CMS-10430_Model_Notice_to_Enrollees_ENGLISH.docx	Yes	No	Paper Only
Other-Notice	CMS-10430_Model_Notice_to_Enrollees_ARABIC.docx	Yes	No	Paper Only
Other-Notice	CMS-10430_Model_Notice_to_Enrollees_FRENCH.docx	Yes	No	Paper Only
Other-Notice	CMS-10430_Model_Notice_to_Enrollees_KOREAN.docx	Yes	No	Paper Only
Other-Notice	CMS-10430_Model_Notice_to_Enrollees_SPANISH.docx	Yes	No	Paper Only
Other-Notice	CMS-10430_Model_Notice_to_Enrollees_TAGALOG.docx	Yes	No	Paper Only
Other-Notice	CMS-10430_Model_Notice_to_Enrollees_TCHINESE.docx	Yes	No	Paper Only
Other-Notice	CMS-10430_Model_Notice_to_Enrollees_VIETNAMESE.docx	Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 587

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 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	12,891	-38,494	51,385
Annual IC Time Burden (Hours)	2,408	622	1,786
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.