Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions

Forms and Documents

Document Name	Status
Form CMS-10466 Exemption Applications - Eligibility for Exemptions Form and Instruction	Modified
CMS-10466 - non-substantive change request.docx Justification for No Material/Nonsubstantive Change	2014-02-27

IC Document Collections

IC ID	Document Title	Status
208103	Agreements	Modified
208102	Periodic Electronic Notifications	Modified
208101	Redeterminations	Modified
205756	Verification of New and Changed Applications	Modified
205755	Eligibility Notices	Modified
205754	Application Development	Modified
205753	Exemption Applications - Eligibility for Exemptions Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1190	ICR Reference No: 201402-0938-015
Status: Historical Active	Previous ICR Reference No: 201311-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No: 21516
Title: Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/07/2014
	Date Received in OIRA: 02/27/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2016	12/31/2016	12/31/2016
Responses	12,000,108	0	12,000,108
Time Burden (Hours)	3,263,605	0	3,263,605
Cost Burden (Dollars)	600,000	0	600,000

---

Abstract: The final rule entitled "Exchange Functions: Eligibility for Exemptions" provides standards with regard to the minimum function of an Exchange to perform eligibility determinations and issue certificates of exemption from the shared responsibility payment. The final rule implements standards related to eligibility for exemptions, including the verification and eligibility determination process, eligibility redeterminations, options for conducting eligibility determinations, and reporting related to exemptions.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 1311 Name of Law: Affordable choices of health benefit plans.
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 7

IC Title	Form No.	Form Name
Eligibility Notices
Exemption Applications - Eligibility for Exemptions	CMS-10466, CMS-10466, CMS-10466, CMS-10466, CMS-10466, CMS-10466, CMS-10466	Application Exemptions - Incarerated ,   Application Exemptions Shared Responsibility for FFM's ,   Exemption Application - Shared Responsibility SBM's ,   Exemption Application - Health Care Sharing Ministries ,   Application for Exemptions Religious Sects or Divis ,   Application Exemption - Hardships ,   Application for Exemption for American Indians
Application Development
Verification of New and Changed Applications
Redeterminations
Periodic Electronic Notifications
Agreements

---

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	12,000,108	12,000,108	0	0	0	0
Annual Time Burden (Hours)	3,263,605	3,263,605	0	0	0	0
Annual Cost Burden (Dollars)	600,000	600,000	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:

---

Annual Cost to Federal Government: $600,000

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: 02/27/2014

---