Individual Application

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

OMB: 0938-1191

IC ID: 205692

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Individual Application
 
No New
 
Required to Obtain or Retain Benefits
 
45 CFR Parts 155, 156, 157 42 CFR Parts 431, 435, 457 26 CFR 1 and 602  (To search for a specific CFR, visit the Code of Federal Regulations.)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10440 AttachmentC-Application for Health Coverage & Help Paying Costs CMS-10440.AttachmentC-Application for Health Coverage & Help Paying Costs.pdf Yes No Fillable Fileable
Form and Instruction CMS-10440 CMS-10440_AttachmentA-Individual Online Application Questionnaire CMS-10440.AttachmentA-Individual Online Application Questionnaire.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10440 CMS_10440_AttachmentD-Application for Health Coverage CMS-10440.AttachmentD-Application for Health Coverage.pdf Yes No Fillable Fileable

Health Health Care Services

 

2,776,698 0
   
Individuals or Households
 
   90 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,776,698 2,776,698 0 0 0 0
Annual IC Time Burden (Hours) 1,407,261 1,407,261 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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