Consumer Operated and Oriented Plan [CO-OP] Program

Forms and Documents

Document	Type	Status	Availability
Form CMS-10392 Recordkeeping	Form and Instruction	Modified	Available
Form CMS-10392 Audits	Form and Instruction	Modified	Available
Form CMS-10392 Enhanced Reporting (Before Loan Repayment) - Start-up/Solvency Loan Recipients	Form and Instruction	Modified	Repair queued
Form CMS-10392 Standard Reporting After Loan Repayment - Start-up/Solvency Loan Recipients	Form and Instruction	Modified	Available
Form CMS-10392 Standard Reporting Before Loan Repayment - Start-up/Solvency Loan(s) Recipients	Form and Instruction	Modified	Available
Form CMS-10392 Loan Agreement Acceptance	Form and Instruction	Modified	Repair queued
Form CMS-10392 Reconsiderations & Appeals	Form and Instruction	Modified	Repair queued
Form CMS-10392 Start-up & Solvency Loan Application	Form and Instruction	Modified	Available
CMS-10392 Supporting Statement Part A1.doc	Supporting Statement A	Uploaded 2012-06-18	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
198657	Recordkeeping	Form and Instruction	Modified
198656	Audits	Form and Instruction	Modified
198655	Enhanced Reporting (Before Loan Repayment) - Start-up/Solvency Loan Recipients	Form and Instruction	Modified
198654	Standard Reporting After Loan Repayment - Start-up/Solvency Loan Recipients	Form and Instruction	Modified
198653	Standard Reporting Before Loan Repayment - Start-up/Solvency Loan(s) Recipients	Form and Instruction	Modified
198652	Loan Agreement Acceptance	Form and Instruction	Modified
198651	Reconsiderations & Appeals	Form and Instruction	Modified
198650	Start-up & Solvency Loan Application	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1139	ICR Reference No: 201201-0938-001
Status: Historical Active	Previous ICR Reference No: 201107-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Consumer Operated and Oriented Plan [CO-OP] Program
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/19/2012
	Date Received in OIRA: 01/03/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	36 Months From Approved	06/30/2012
Responses	883	0	876
Time Burden (Hours)	36,111	0	31,998
Cost Burden (Dollars)	0	0	0

---

Abstract: The data collection in this package includes requirements associated with the Consumer Operated and Oriented Plan [CO-OP] Program, which includes Loan applications; Reconsideration requests and appeals; Loan Agreement acceptance and execution; Milestone updates; Financial reports; Progress reports; Enhanced financial and progress reports; Audits; and Recordkeeping.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 1322 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AQ98	Final or interim final rulemaking	76 FR 77392	12/13/2011

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 8

IC Title	Form No.	Form Name
Start-up & Solvency Loan Application	CMS-10392	CO-OP FOA
Reconsiderations & Appeals	CMS-10392	CO-OP FOA
Loan Agreement Acceptance	CMS-10392	CO-OP FOA
Standard Reporting Before Loan Repayment - Start-up/Solvency Loan(s) Recipients	CMS-10392, CMS-10392	CO-OP FOA ,   Reporting Templates
Standard Reporting After Loan Repayment - Start-up/Solvency Loan Recipients	CMS-10392, CMS-10392	CO-OP FOA ,   Reporting Templates
Enhanced Reporting (Before Loan Repayment) - Start-up/Solvency Loan Recipients	CMS-10392, CMS-10392, CMS-10392	Reporting Templates ,   Deliberative Document ,   CO-OP FOA
Audits	CMS-10392	CO-OP FOA
Recordkeeping	CMS-10392	CO-OP FOA

---

ICR Summary 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	883	876	0	0	7	0
Annual Time Burden (Hours)	36,111	31,998	0	0	4,113	0
Annual Cost Burden (Dollars)	0	0	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: $361,706

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: 01/03/2012

---