Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10371 Exchange Establishment Grant FOA	Form and Instruction	New	Available
Form CMS-10371 Exchange Establishment Grant FOA	Form and Instruction	New	Available
Form CMS-10371 Operational Metric – SBM Open Enrollment Weekly Indicators	Form and Instruction	New	Available
Form CMS-10371 Exchange Establishment Grants FOA	Form and Instruction	New	Available
Form CMS-10371 Operational Metric – SBM Open Enrollment Weekly Indicators	Form and Instruction	New	Available
Form CMS-10371 Outcome Metrics - Annual Report	Form and Instruction	New	Available
Form CMS-10371 Outcome Metric – SBM Exchange Metrics	Form and Instruction	New	Available
Form CMS-10371 Start-up Outcomes Metrics - Quarterly Reports	Form and Instruction	New	Available
Form CMS-10371 Outcome Metric – SBM Exchange Metrics	Form and Instruction	New	Available
Form CMS-10371 Revised FOA	Form and Instruction	Modified	Available
Form CMS-10371 Establishment Grant FOA	Form and Instruction	Modified	Available
Form CMS-10371 Revised FOA	Form and Instruction	Modified	Available
Form CMS-10371 Revised FOA	Form and Instruction	Modified	Available
Form CMS-10371 Revised FOA	Form and Instruction	Modified	Available
Form CMS-10371 Revised FOA	Form and Instruction	Modified	Available
CMS-10371.Emergency Justification.pdf	Supplementary Document	Uploaded 2013-09-18	Available
0938-1119_REVISED Supporting Statement (9-6-13).docx	Supporting Statement A	Uploaded 2013-09-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208348	Develpomental Phase Planning Review	Form and Instruction	New	Exchange Establishment Grant FOA
208347	Start-Up Year Establishment Review	Other-Data Elements	New
208346	Operational Metrics - Weekly Reports	Form and Instruction	New	Exchange Establishment Grant FOA
208346	Operational Metrics - Weekly Reports	Form and Instruction	New	Operational Metric – SBM Open Enrollment Weekly Indicators
208345	Operational Metrics - Monthly Reports	Form and Instruction	New	Exchange Establishment Grants FOA
208345	Operational Metrics - Monthly Reports	Form and Instruction	New	Operational Metric – SBM Open Enrollment Weekly Indicators
208344	Outcome Metrics - Annual Report	Form and Instruction	New	Outcome Metrics - Annual Report
208344	Outcome Metrics - Annual Report	Form and Instruction	New	Outcome Metric – SBM Exchange Metrics
208343	Start-up Outcomes Metrics - Quarterly Reports	Form and Instruction	New	Start-up Outcomes Metrics - Quarterly Reports
208343	Start-up Outcomes Metrics - Quarterly Reports	Form and Instruction	New	Outcome Metric – SBM Exchange Metrics
198691	Work Plan Update	Form and Instruction	Modified	Revised FOA
198690	Semi-Annual Reports	Form and Instruction	Modified	Establishment Grant FOA
198689	Public	Form and Instruction	Modified	Revised FOA
198688	Periodic Reporting	Form and Instruction	Modified	Revised FOA
198687	Performance Reviews	Form and Instruction	Modified	Revised FOA
195986	Application	Form and Instruction	Modified	Revised FOA

ICR Details

OMB Control No: 0938-1119	ICR Reference No: 201308-0938-024
Status: Historical Active	Previous ICR Reference No: 201203-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: 20357
Title: Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/30/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/23/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2016	36 Months From Approved	09/30/2014
Responses	1,068	0	700
Time Burden (Hours)	67,884	0	69,650
Cost Burden (Dollars)	28,081	0	42,770

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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 choices of health benefit plans
  

Citations for New Statutory Requirements: None

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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:
	78 FR 31557	05/24/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 50057	08/16/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 12

table that charts list of burden

IC Title	Form No.	Form Name
Application	CMS-10371	Revised FOA
Develpomental Phase Planning Review	CMS-10371	Exchange Establishment Grant FOA
Operational Metrics - Monthly Reports	CMS-10371, CMS-10371	Exchange Establishment Grants FOA ,   Operational Metric – SBM Open Enrollment Weekly Indicators
Operational Metrics - Weekly Reports	CMS-10371, CMS-10371	Exchange Establishment Grant FOA ,   Operational Metric – SBM Open Enrollment Weekly Indicators
Outcome Metrics - Annual Report	CMS-10371, CMS-10371	Outcome Metrics - Annual Report ,   Outcome Metric – SBM Exchange Metrics
Performance Reviews	CMS-10371	Revised FOA
Periodic Reporting	CMS-10371	Revised FOA
Public	CMS-10371	Revised FOA
Semi-Annual Reports	CMS-10371	Establishment Grant FOA
Start-Up Year Establishment Review
Start-up Outcomes Metrics - Quarterly Reports	CMS-10371, CMS-10371	Start-up Outcomes Metrics - Quarterly Reports ,   Outcome Metric – SBM Exchange Metrics
Work Plan Update	CMS-10371	Revised FOA

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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	1,068	700	0	-120	488	0
Annual Time Burden (Hours)	67,884	69,650	0	-13,288	11,522	0
Annual Cost Burden (Dollars)	28,081	42,770	0	0	-14,689	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The more substantial current revisions result in a net reduction in annual burden of over 4,000 hours and a net reduction of over $360,000 in annual cost to the respondents. These revisions to the ICR are necessary to reflect the maturation of the Marketplace development as well as the need for more robust oversight and monitoring of the grantees in their Start-up year. The revised estimates of respondents reflect the actual participation of States in these grants; while initially the estimate included all eligible jurisdictions, the current estimate is based on grants awarded through April 2013, and the anticipated grant requests and entry into Marketplace Development and Start-up. Revisions to the Establishment Review delineation of tasks appropriately reflect the comprehensive preparation required for the series of planning, design and implementation reviews during the Developmental Phase. In addition, during the Start-up year, there are robust additional monitoring requirements; these Outcomes and Performance Metrics have been developed as needs for critical performance assessment has been identified. An increase in reporting is offset by the previous reductions in reporting frequency, and more accurate number of respondents for many of the reports.

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Annual Cost to Federal Government: $394,912

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: 08/23/2013

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