CMS-10433 Plan Benefits Template

OMB Control Number: 0938-1187
Expiration Date: XX/XX/20XX

Plan Crosswalk Template v12.0

Issuer Information

Actions

HIOS Issuer ID*
Issuer State*
Market Coverage*
Dental Only Plan*

1.

Import 2022 Plans & Benefits Template and Service Area Template

Please save your completed 2022 Plans & Benefits Template and Service Area Template to a folder on
your harddrive and then select the button below to import the data.

2022 HIOS Plan ID
(Standard Component)

Crosswalk Level

Counties Crosswalked at Zip Level

Required

Required: Indicate whether you would like to crosswalk your 2022 to 2023 Plan IDs at
the plan, county or zip code level.

Required if user indicates Crosswalked at the Zip Level
for one or more counties.

2.

Create "2023 Crosswalk Tab"

Select the button below to create the 2023 Crosswalk Tab based upon your entry.

3.

Validate Data

Select the button below to validate information entered into all tabs. Warning : Depending on
data size, validation may take several minutes.

4.

Finalize Template

Select the button below to export data to XML file.

PRA DISCLOSURE:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1187, expiration
date is XX/XX/20XX. The time required to complete this information collection is estimated to take up to 24.50 hours per issuer per year, including the time to review instructions, gather the information needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Nicole
Levesque at Nicole.Levesque@cms.hhs.gov.

on

2022 HIOS Plan ID
(Standard
Component)

Service Area ID

Service Area Name

2022 State

County Name

Partial County

Service Area Zip
Code(s)