Application

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1119 can be found here:

Documents and Forms

Document Name Document Type
0938-1119 - FOA - Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges.pdf Instruction
CMS-10371 FOA 0938-1119.Amended Exchange Establishment FOA.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			0938-1119 - FOA - Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges.pdf		Yes	Yes	Paper Only
Form and Instruction	CMS-10371	FOA	0938-1119.Amended Exchange Establishment FOA.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	28,200	28,200
Annual IC Cost Burden (Dollars)	42,770	42,770

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.