Reinsurance and Risk Adjustment

Initial Plan Data Collection to Support QHP Certification and other Financial Management and Exchange Operations

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1187 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10433 Reinsurance and Risk Adjustment Form and Instruction
CMS-10433 Appendix D 1 RI, RA, Banking, Edge Server Data Elements 21 - Appendix D 1 RI, RA, Banking, Edge Server Data Elements.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Reinsurance and Risk Adjustment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 153.220, 410, 540, 610

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10433	Appendix D 1 RI, RA, Banking, Edge Server Data Elements	21 - Appendix D 1 RI, RA, Banking, Edge Server Data Elements.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	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 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	3,800	3,800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.