Initial Plan Data Collection to Support QHP Certification and other Financial Management and Exchange Operations (CMS-10433)

OMB 0938-1187

As required by the CMS-9989-F: Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers ("Exchange rule"), each Exchange must assume responsibilities related to the certification and offering of Qualified Health Plans ("QHP"). To offer insurance through an Exchange, a health insurance issuer must have its health plans certified as QHPs by the Exchange. A QHP must meet certain minimum certification standards, such as network adequacy, actuarial value standards, and the offering of the essential health benefits (EHB). The Exchange is responsible for ensuring that QHPs meet these minimum certification standards as described in the Exchange rule under 45 CFR 155 and 156, based on the Affordable Care Act, as well as other requirements determined by the Exchange.

The latest form for Initial Plan Data Collection to Support QHP Certification and other Financial Management and Exchange Operations (CMS-10433) expires 2022-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10433 Risk Adjustment Form and Instruction
Form CMS-10433 QHP Certification Form and Instruction
CMS-10433 QHP Certification Supporting Statement 30-Day_02.18.22.docx Supporting Statement A
Stand-Alone Dental Issuers: QHP Certification
States: SBE's, Federal Platform and Partnership States
Risk Adjustment Form and Instruction
QHP Certification Form and Instruction

All Historical Document Collections

202204-0938-007 Approved with change	Revision of a currently approved collection	2022-04-19
201902-0938-012 Approved with change	Revision of a currently approved collection	2019-02-28
201511-0938-013 Approved without change	Revision of a currently approved collection	2015-11-27
201505-0938-004 Approved without change	Reinstatement without change of a previously approved collection	2015-05-07
201409-0938-005 Approved without change	Revision of a currently approved collection	2014-09-11
201402-0938-008 Approved with change	Revision of a currently approved collection	2014-02-12
201303-0938-004 Approved with change	New collection (Request for a new OMB Control Number)	2013-03-07

OMB Details

QHP Certification

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-10433	Administrative Data Template	Fillable Fileable	Form and instruction
Form CMS-10433	Reinsurance Program and Risk Adjustment Program	Fillable Fileable	Form and instruction
Form CMS-10433	QHP Certification Instrument Screenshots	Fillable Fileable	Form and instruction
Form CMS-10433	Service Area Template	Fillable Fileable	Form and instruction
Form CMs-10433	Business Rules Template	Fillable Fileable	Form and instruction
Form CMS-10433	Rate Table Template	Fillable Fileable	Form and instruction
Form CMS-10433	Prescriptions Drug Formulary Template	Fillable Fileable	Form and instruction
Form CMS-10433	Plans and Benefits Template	Fillable Fileable	Form and instruction
Form CMS-10433	Network ID Template	Fillable Fileable	Form and instruction
Form CMS-10433	Plan Benefits Template	Fillable Fileable	Form and instruction
Form CMS-10433	Network Adequacy Template	Fillable Fileable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.