Information Collection

QHP Certification

IC 206068 under ICR 202604-0938-001 · OMB 0938-1187.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10433 Administrative Data Template QHP Certification	Form and Instruction
Form CMS-10433 Plan Benefits Template QHP Certification	Form and Instruction
Form CMS-10433 Network ID Template QHP Certification	Form and Instruction
Form CMS-10433 Plans and Benefits Template QHP Certification	Form and Instruction
Form CMS-10433 Prescriptions Drug Formulary Template QHP Certification	Form and Instruction
Form CMS-10433 Rate Table Template QHP Certification	Form and Instruction
Form CMS-10433 Service Area Template QHP Certification	Form and Instruction
Form CMs-10433 Business Rules Template QHP Certification	Form and Instruction
Form CMS-10433 QHP Certification Instrument Screenshots QHP Certification	Form and Instruction
Form CMS-10433 Reinsurance Program and Risk Adjustment Program QHP Certification	Form and Instruction
K_ECP_Data_Elements_508.pdf	Other-Data Elements
CMS-10433 Administrative Data Template A_Accreditation_Administrative_Web_Form_508.pdf	Form and Instruction
CMS-10433 Plan Benefits Template C_Plan_ID_Crosswalk_PY2025_Template_508.pdf	Form and Instruction
CMS-10433 Network ID Template B_URL_Template_508.pdf	Form and Instruction
CMS-10433 Plans and Benefits Template D_Plans_and_Benefits_Template_508.pdf	Form and Instruction
CMS-10433 Prescriptions Drug Formulary Template E_Prescription_Drug_Template_508.pdf	Form and Instruction
CMS-10433 Rate Table Template G_Rates_Table_Template_508.pdf	Form and Instruction
CMS-10433 Service Area Template I_Service_Area_Template_508.pdf	Form and Instruction
CMs-10433 Business Rules Template H_Business_Rules_Template_508.pdf	Form and Instruction
CMS-10433 QHP Certification Instrument Screenshots J_Interoperability_Web_Form_508.pdf	Form and Instruction
CMS-10433 Reinsurance Program and Risk Adjustment Program F_RA_Programs_Payment_Ops_Data_508.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

QHP Certification

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.1065 45 CFR 156.200

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10433	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Yes	Yes	Fillable Fileable
Form and Instruction	CMs-10433	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10433	Yes	Yes	Fillable Fileable
Other-Data Elements		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: 215

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
	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	215	215
Annual IC Time Burden (Hours)	42,140	42,140
Annual IC Cost Burden (Dollars)	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.

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