Program Integrity and Additional State Information Collections

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Appendix E - Part 156 Subpart I .pdf	Supplementary Document	Uploaded 2013-09-13	Available
Appendix D - AV Continuance Tables.xlsm	Supplementary Document	Uploaded 2013-09-13	Available
Appendix C - Habilitative Services.pdf	Supplementary Document	Uploaded 2013-09-13	Available
Appendix B Data Elements for Notices Part 155 156 157 .pdf	Supplementary Document	Uploaded 2013-09-13	Available
Appendix A - Agents and Brokers.pdf	Supplementary Document	Uploaded 2013-09-13	Available
CMS-10490.Supporting Statement Part A.docx	Supporting Statement A	Uploaded 2013-09-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208543	45 CFR 156.1230		Removed
208542	45 CFR 156.1210		Removed
208540	45 CFR 156.1230		Removed
208539	45 CFR 156.1210		Removed
208538	45 CFR 156.1010		Removed
208537	45 CFR 156.901-156.963		Removed
208536	45 CFR 156.715		Removed
208535	45 CFR 156.715		Removed
208534	156.1230(a)(2)		Modified
208533	156.1230(a)(1)		Modified
208532	156.1010		Modified
208531	156.135		Modified
208530	155.115 - Habilitative Services		Modified
208529	Notices		Modified
208528	Records Storage		Modified
208527	Notice of Appeals Actions		Modified
208526	Forms - Appeal Withdrawal, Request to Vacate a Dismissal, Special Considerations and Appointment of Authorized Representative		Modified
208525	Evidence Submission		Modified
208524	Appeals		Modified
208523	Appeals - Appeal Form		Modified
208522	155.310(k)		Modified
208521	155.260 - Agents and Brokers		Modified
208520	155.260 - Certified Application Counselors		Modified
208519	155.260 - Navigators		Modified
208518	155.220(g)(2)		Modified
208517	155.220(c)(4)		Modified
208516	155.220(c)(3)(vii)		Modified

ICR Details

OMB Control No: 0938-1213	ICR Reference No: 201309-0938-019
Status: Historical Active	Previous ICR Reference No: 201307-0938-016
Agency/Subagency: HHS/CMS	Agency Tracking No: 20541
Title: Program Integrity and Additional State Information Collections
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 without change	Conclusion Date: 11/21/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/17/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2016	36 Months From Approved
Responses	432,468	0	0
Time Burden (Hours)	1,773,090	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The data collections and third-party disclosure requirements will assist HHS in determining Exchange compliance with Federal standards. The data collection and third-party disclosure requirements will also assist HHS in monitoring QHP issuers in FFEs for compliance with Federal QHP issuer standards. The data collected by health insurance issuers and Exchanges will help to inform HHS, Exchanges, and health insurance issuers as to the participation of individuals, employers, and employees in the individual Exchange, the SHOP, and the premium stabilization programs.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1321(a) Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 148 1321(c)(1) Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 148 1321(c)(2) Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 148 1312(e) Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 148 1311(c)(4) Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 148 1313 Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 148 1342 Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 148 1401 Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 148 1411-1413 Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 148 1402 Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 148 2201 Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 148 1302(a)(3) Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 148 1302(d)(2)(A) Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1311(c)(4) Name of Law: Affordable Care Act
PL: Pub.L. 111 - 148 1321(a) Name of Law: Affordable Care Act
PL: Pub.L. 111 - 148 1321(c)(1) Name of Law: Affordable Care Act
PL: Pub.L. 111 - 148 1321(c)(2) Name of Law: Affordable Care Act
PL: Pub.L. 111 - 148 1312(e) Name of Law: Affordable Care Act
PL: Pub.L. 111 - 148 1313 Name of Law: Affordable Care Act
PL: Pub.L. 111 - 148 1342 Name of Law: Affordable Care Act
PL: Pub.L. 111 - 148 1401 Name of Law: Affordable Care Act
PL: Pub.L. 111 - 148 1411-1413 Name of Law: Affordable Care Act
PL: Pub.L. 111 - 148 1402 Name of Law: Affordable Care Act
PL: Pub.L. 111 - 148 2201 Name of Law: Affordable Care Act
PL: Pub.L. 111 - 148 1302(a)(3) Name of Law: Affordable Care Act
PL: Pub.L. 111 - 148 1302(d)(2)(A Name of Law: Affordable Care Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AR82	Final or interim final rulemaking	78 FR 54069	08/30/2013

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 19

table that charts list of burden

IC Title	Form No.	Form Name
155.115 - Habilitative Services
155.220(c)(3)(vii)
155.220(c)(4)
155.220(g)(2)
155.260 - Agents and Brokers
155.260 - Certified Application Counselors
155.260 - Navigators
155.310(k)
156.1010
156.1230(a)(1)
156.1230(a)(2)
156.135
45 CFR 156.1010
45 CFR 156.1210
45 CFR 156.1210
45 CFR 156.1230
45 CFR 156.1230
45 CFR 156.715
45 CFR 156.715
45 CFR 156.901-156.963
Appeals
Appeals - Appeal Form
Evidence Submission
Forms - Appeal Withdrawal, Request to Vacate a Dismissal, Special Considerations and Appointment of Authorized Representative
Notice of Appeals Actions
Notices
Records Storage

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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	432,468	0	432,468	0	0	0
Annual Time Burden (Hours)	1,773,090	0	1,773,090	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 new information collection request.

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Annual Cost to Federal Government: $0

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: 09/16/2013

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