Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10371 Work Plan Update	Form and Instruction	Modified	Available
Form CMS-10371 Quarterly	Form and Instruction	Modified	Available
Form CMS-10371 Public	Form and Instruction	Modified	Available
Form CMS-10371 Performance Reviews	Form and Instruction	Modified	Available
0938-1119 - Justification of Non-material change.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2011-11-22	Available
0938-0119 - Supporting Statement A - 09.16.11.doc	Supporting Statement A	Uploaded 2011-11-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
198691	Work Plan Update	Form and Instruction	Modified
198690	Quarterly	Form and Instruction	Modified
198689	Public	Form and Instruction	Modified
198688	Periodic Reporting	Instruction	Modified
198687	Performance Reviews	Form and Instruction	Modified
195986	Application	Instruction	Modified

ICR Details

OMB Control No: 0938-1119	ICR Reference No: 201111-0938-011
Status: Historical Active	Previous ICR Reference No: 201107-0938-018
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/28/2011
	Date Received in OIRA: 11/22/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2014	09/30/2014	09/30/2014
Responses	700	0	700
Time Burden (Hours)	69,650	0	69,650
Cost Burden (Dollars)	42,770	0	42,770

---

Abstract: Information collected as a part of the application for this grant will be used to evaluate the applications and determine awardees. Information collected pursuant to the reporting requirements for awardees will be used to evaluate the progress of States in planning for and implementing Exchanges, and determine how the Secretary can provide assistance to achieve the goals of the grant program and the Affordable Care Act.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 1311 Name of Law: Affordable choices of health benefit plans
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Application	CMS-10371	FOA
Performance Reviews	CMS-10371	FOA
Periodic Reporting	CMS-10371	FOA
Public	CMS-10371	FOA
Quarterly	CMS-10371, CMS-10371, CMS-10371, CMS-10371	Quarterly Instrument ,   Quarterly Data Elements ,   Quarterly Instrument Revised ,   Quarterly Data Elements Revised
Work Plan Update	CMS-10371	FOA

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	700	700	0	0	0	0
Annual Time Burden (Hours)	69,650	69,650	0	0	0	0
Annual Cost Burden (Dollars)	42,770	42,770	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $3,760

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/22/2011

---