Form CMS-10333 Screenshot

Additional Disclosure: CCIIO developed a database for collecting, tracking, and reporting consumer
complaints data, and made it available, free of charge, to Consumer Assistance Program (CAP) grantees
(pursuant to Section 2793 of the PHS Act, as amended by Section 1002 of the Affordable Care Act) for use in
tracking and reporting data on consumer complaints to CCIIO. A separate emergency Paperwork Reduction Act
package was approved on February 15, 2011 for the Caseworker Tool for the exclusive use of CAP grantees.
The use of the Caseworker Tool by CAPs is separate and distinct from the use of the Caseworker Tool for
purposes of the Health Insurance Assistance Team in CCIIO for which this PRA package is being submitted.

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Health Insurance Options Following Loss/Change of Other Coverage –
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