Data Collection to Support Eligibility Determinations and Enrollment for Employees in the Small Business Health Options Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10438 SHOP - Employee	Form and Instruction	New	Available
CMS-10438 SHOP Employee Comment Chart 5-10-13.xlsx	Supplementary Document	Uploaded 2013-05-10	Available
CMS-10438-SHOP Supporting Statement Employee 5-10-13.docx	Supporting Statement A	Uploaded 2013-05-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
205690	SHOP - Employee	Form and Instruction	New

ICR Details

OMB Control No: 0938-1194	ICR Reference No: 201302-0938-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 18757
Title: Data Collection to Support Eligibility Determinations and Enrollment for Employees in the Small Business Health Options Program
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: 05/31/2013
	Date Received in OIRA: 02/05/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2016	36 Months From Approved
Responses	888,888	0	0
Time Burden (Hours)	180,178	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: On March 23, 2010, the President signed into law H.R. 3590, the Patient Protection and Affordable Care Act, Public Law 111-148, as amended by the Health Care and Education Reconciliation Act of 2010, Pub. L. 111-152, collectively referred to as "The Affordable Care Act." The Affordable Care Act expands access to health insurance coverage through improvements to the Medicaid and Children's Health Insurance (CHIP) programs, the establishment of Affordable Insurance Exchanges (Exchanges), and the assurance of coordination between Medicaid, CHIP, and Exchanges. Through the Small Business Health Options Program (SHOP), the new Exchanges will assist qualified employers who are small employers in facilitating the enrollment of their employees in Qualified Health Plans (QHPs) offered in the small group market. The Exchanges, which will offer these QHPs, will become operational on January 1, 2014. Qualified employees of employers participating in the SHOP will be able to begin applying for enrollment in QHPs through the SHOP October 1, 2013, for coverage beginning as early as January 1, 2014. The employee's application for the SHOP will be a single, streamlined form that will be used to determine employee eligibility. The submission seeks OMB approval of the data collection elements needed to support eligibility determinations for employees in the SHOP.

---

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

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 40061	07/06/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 6109	01/29/2013
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
SHOP - Employee	CMS-10438, CMS-10438	Appendix_B-SHOP_Employee_Application ,   Appendix_A-SHOP_Employee_List_of_Questions

---

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	888,888	0	888,888	0	0	0
Annual Time Burden (Hours)	180,178	0	180,178	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.

---

Annual Cost to Federal Government: $502,350

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: 02/05/2013

---