Cooperative Agreement to Support Establishment of the Affordable Care Act's Health Insurance Exchanges

Forms and Documents

Document Name	Status
Form CMS-10424 Public Report Form and Instruction	New
Form CMS-10424 Progress Report Form and Instruction	New
Form CMS-10424 Funding Opportunity Announcement Application Form and Instruction	New
Response to Public Comments.docx Supplementary Document	2012-05-21
CMS-10424_Supporting_Statement_A.pdf Supporting Statement A	2012-05-21

IC Document Collections

IC ID	Document Title	Status
202384	Establishment Review Instruction	New
202383	Public Report Form and Instruction	New
202382	Progress Report Form and Instruction	New
202381	Funding Opportunity Announcement Application Form and Instruction	New

ICR Details

OMB Control No: 0938-1168	ICR Reference No: 201205-0938-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Cooperative Agreement to Support Establishment of the Affordable Care Act's Health Insurance Exchanges
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/28/2012
	Date Received in OIRA: 05/21/2012
Terms of Clearance: Within 3 business days of this approval, the agency will submit a "non-substantive" change to update the electronic record with a copy of the FOA.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	36 Months From Approved
Responses	357	0	0
Time Burden (Hours)	50,159	0	0
Cost Burden (Dollars)	0	0	0

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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.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1311 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1311 Name of Law: Affordable Care Act

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 12847	03/19/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 29646	05/18/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Funding Opportunity Announcement Application	CMS-10424	FOA
Progress Report	CMS-10424	Progress Report
Public Report	CMS-10424	Progress Report
Establishment Review

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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	357	0	357	0	0	0
Annual Time Burden (Hours)	50,159	0	50,159	0	0	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: This is a new information collection request.

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Annual Cost to Federal Government: $142,390

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

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Common Form ICR:  No

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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: 05/21/2012

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