Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and Children's Health Insurance Program Agencies

Forms and Documents

Document Name	Status
Form CMS-10440 Application for Health Coverage and Help Paying Costs Short Form Form and Instruction	New
Form CMS-10440 Individual Application Form and Instruction	New
PRA Comments Table for OMB.docx Supplementary Document	2013-02-04
CMS-10440_Appendix_B_Video_Description_and_URL.pdf Supplementary Document	2013-02-04
CMS-10440.Supporting Statement Part A.docx Supporting Statement A	2013-04-25

IC Document Collections

IC ID	Document Title	Status
206713	Application for Health Coverage and Help Paying Costs Short Form Form and Instruction	New
205692	Individual Application Form and Instruction	New

ICR Details

OMB Control No: 0938-1191	ICR Reference No: 201302-0938-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 18760
Title: Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and Children's Health Insurance Program Agencies
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: 04/30/2013
	Date Received in OIRA: 02/05/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2016	36 Months From Approved
Responses	3,035,434	0	0
Time Burden (Hours)	1,428,822	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Section 1413 of the Affordable Care Act directs the Secretary of HHS to develop and provide to each State a single, streamlined form that may be used to apply for coverage through the Exchange and Insurance Affordability Programs. A state may develop and use its own single streamlined application if approved by the Secretary in accordance with section 1413 and if it meets the standards established by the Secretary.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1413 Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 152 . Name of Law: Health Care and Education Reconciliation Act of 2010
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1413 Name of Law: Affordable Care Act
PL: Pub.L. 111 - 152 . Name of Law: Health Care and Education Reconciliation Act of 2010

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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 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

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Individual Application	CMS-10440, CMS-10440, CMS-10440	AttachmentC-Application for Health Coverage & Help Paying Costs ,   CMS-10440_AttachmentA-Individual Online Application Questionnaire ,   CMS_10440_AttachmentD-Application for Health Coverage
Application for Health Coverage and Help Paying Costs Short Form	CMS-10440	CMS-10440.AttachmentB-Application for Health Coverage & Help Paying Costs (Short Form)

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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	3,035,434	0	3,035,434	0	0	0
Annual Time Burden (Hours)	1,428,822	0	1,428,822	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: $834,492

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: 02/05/2013

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