Annual Submission of Transparency in Coverage Data

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1310 can be found here:

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_Transparency in Coverage_Appendix A2.pdf Form and Instruction
CMS-10572 QHP Issuer Data Collection - Appendix A2 CMS-10572_Transparency in Coverage_Appendix A2.pdf Form and Instruction
CMS-10572 Data Submission Template - Appendix C CMS-10572_Transparency in Coverage_Appendix C.pdf Form and Instruction
CMS-10572 Data Submission Template - Appendix C CMS-10572_Transparency in Coverage_Appendix C.pdf Form and Instruction
CMS-10572 Data Elements - Appendix A1 CMS-10572_Transparency in Coverage_Apppendix A1.pdf Form and Instruction
CMS-10572 Data Elements - Appendix A1 CMS-10572_Transparency in Coverage_Apppendix A1.pdf Form and Instruction
CMS-10572 Data Templates Appendix B CMS-10572_Transparency in Coverage_Appendix B1.pdf Form and Instruction
CMS-10572 Data Templates Appendix B CMS-10572_Transparency in Coverage_Appendix B1.pdf Form and Instruction
CMS-10572 Data Template Appendix B2 CMS-10572_Transparency in Coverage_Appendix B2.pdf Form and Instruction
CMS-10572 Data Template Appendix B2 CMS-10572_Transparency in Coverage_Appendix B2.pdf Form and Instruction
CMS-10572 Data Template - Appendix D CMS-10572_Transparency in Coverage_Appendix D.pdf Form and Instruction
CMS-10572 Data Template - Appendix D CMS-10572_Transparency in Coverage_Appendix D.pdf 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_Transparency in Coverage_Appendix A2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Submission Template - Appendix C	CMS-10572_Transparency in Coverage_Appendix C.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Elements - Appendix A1	CMS-10572_Transparency in Coverage_Apppendix A1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Templates Appendix B	CMS-10572_Transparency in Coverage_Appendix B1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Template Appendix B2	CMS-10572_Transparency in Coverage_Appendix B2.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10572	Data Template - Appendix D	CMS-10572_Transparency in Coverage_Appendix D.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 360	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 Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	360	0	-110	470
Annual IC Time Burden (Hours)	51,480	1,178	50,260	42
Annual IC Cost Burden (Dollars)	0	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.