Information Collection Request

Essential Health Benefits Benchmark Plans (CMS-10448)

ICR 202311-0938-014 · OMB 0938-1174 · Received in OIRA

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1174 can be found here:

Forms and Documents

Document Name	Status
Form CMS-10448 EHB Benchmark Plan Formulary Drug Form and Instruction	Modified
Form CMS-10448 State's EHB-benchmark Plan's Benefits and Limits Form and Instruction	Modified
Form CMS-10488 EHB Reporting - EHB Actuarial Certificate Template Form and Instruction	Modified
Form CMS-10448 Confirmations on the State EHB-benchmark Plan Form and Instruction	Modified
CMS-10448_EHB_Substantive_Supporting_Statement_508.docx Supporting Statement A	2024-02-12

IC Document Collections

IC ID	Document Title	Status
241291	EHB Benchmark Plan Formulary Drug Form and Instruction	Modified
231104	State's EHB-benchmark Plan's Benefits and Limits Form and Instruction	Modified
229047	EHB Reporting - EHB Actuarial Certificate Template Form and Instruction	Modified
203740	Confirmations on the State EHB-benchmark Plan Form and Instruction	Modified

ICR Details

Status	Received in OIRA
Agency/Subagency	HHS/CMS
OMB Control No	0938-1174
Type of Information Collection	Revision of a currently approved collection
Previous ICR Reference No	202006-0938-008
Agency Tracking No	CCIIO
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31