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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10424 Progress Report	Form and Instruction	New	Available
Form CMS-10424 Progress Report	Form and Instruction	New	Repair queued
Form CMS-10424 FOA	Form and Instruction	New	Available
Response to Public Comments.docx	Supplementary Document	Uploaded 2012-05-21	Available
CMS-10424_Supporting_Statement_A.pdf	Supporting Statement A	Uploaded 2012-05-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
202384	Establishment Review	Instruction	New
202383	Public Report	Other-Data Elements	New
202383	Public Report	Form and Instruction	New	Progress Report
202382	Progress Report	Other-Data Elements	New
202382	Progress Report	Form and Instruction	New	Progress Report
202381	Funding Opportunity Announcement Application	Form and Instruction	New	FOA

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
Retrieve Notice of Action (NOA)	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.

table that charts list comparision

	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

table that charts list of burden

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

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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	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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