Annual Submission of Transparency in Coverage Data

Information Collection for Transparency in Coverage Reporting by Qualified Health Plan Issuers (CMS-10572)

Documents and Forms

Document Name Document Type
Form CMS-10572 Annual Submission of Transparency in Coverage Data Form and Instruction
CMS-10572 QHP Issuer Data Collection - Appendix A2 CMS-10572 - Appendix A2.docx Form and Instruction
CMS-10572 Data Submission Template - Appendix C CMS-10572 - Appendix C.docx Form and Instruction
CMS-10572 Data Elements - Appendix A1 CMS-10572 - Appendix A1.docx Form and Instruction
CMS-10572 Data Templates Appendix B CMS-10572 - Appendix_B1_508.docx Form and Instruction
CMS-10572 Data Template Appendix B2 CMS-10572 - Appendix B2.docx Form and Instruction
CMS-10572 Data Template - Appendix D CMS-10572 - Appendix D.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Annual Submission of Transparency in Coverage Data	Agency IC Tracking Number:	10572

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.220 45 CFR 156.20

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10572	QHP Issuer Data Collection - Appendix A2	CMS-10572 - Appendix A2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Submission Template - Appendix C	CMS-10572 - Appendix C.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Elements - Appendix A1	CMS-10572 - Appendix A1.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Templates Appendix B	CMS-10572 - Appendix_B1_508.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Template Appendix B2	CMS-10572 - Appendix B2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Template - Appendix D	CMS-10572 - Appendix D.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	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 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	400	40	360
Annual IC Time Burden (Hours)	57,200	5,720	51,480
Annual IC Cost Burden (Dollars)	0	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.