Information Collection Request

Essential Health Benefits Benchmark Plans (CMS-10448)

ICR 202408-0938-009 · OMB 0938-1174 · Received in OIRA

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.docx Supporting Statement A	2024-08-08

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	Reinstatement with change of a previously approved collection
Previous ICR Reference No	202311-0938-014
Agency Tracking No	CCIIO
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31