Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges (CMS-10371)

Forms and Documents

Document	Type	Status	Availability
Form CMS-10371 Budget Report	Form and Instruction	New	Available
Form CMS-10371 Implementation Review	Form and Instruction	Modified	Repair queued
Form CMS-10371 Weekly Reports	Form and Instruction	Modified	Repair queued
Form CMS-10371 Monthly Reports	Form and Instruction	Modified	Repair queued
Form CMS-10371 Annual Report	Form and Instruction	Modified	Available
Form CMS-10371 Quarterly Reports	Form and Instruction	Modified	Repair queued
Form CMS-10371 Work Plan Update	Form and Instruction	Modified	Available
Form CMS-10371 Semi-Annual Reports	Form and Instruction	Modified	Repair queued
Form CMS-10371 Public - Progress Reports	Form and Instruction	Modified	Available
Form CMS-10371 Periodic Reporting	Form and Instruction	Removed	Repair queued
Form CMS-10371 Performance Reviews	Form and Instruction	Removed	Repair queued
Form CMS-10371 Application	Form and Instruction	Removed	Repair queued
OMB_0938-1119 - Supporting Statement 30 day Review .docx	Supporting Statement A	Uploaded 2015-04-24	Available
CMS-10371 Appendix A Comment Summary 4-01-15 DP NS.pdf	Supplementary Document	Uploaded 2015-04-22	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
216248	Budget Report	Form and Instruction	New
208348	Implementation Review	Form and Instruction	Modified
208347	Start-Up Year Establishment Review	Other-Data Elements	Removed
208346	Weekly Reports	Form and Instruction	Modified
208345	Monthly Reports	Form and Instruction	Modified
208344	Annual Report	Form and Instruction	Modified
208343	Quarterly Reports	Form and Instruction	Modified
198691	Work Plan Update	Form and Instruction	Modified
198690	Semi-Annual Reports	Form and Instruction	Modified
198689	Public - Progress Reports	Form and Instruction	Modified
198688	Periodic Reporting	Form and Instruction	Removed
198687	Performance Reviews	Form and Instruction	Removed
195986	Application	Form and Instruction	Removed

ICR Details

OMB Control No: 0938-1119	ICR Reference No: 201504-0938-011
Status: Historical Active	Previous ICR Reference No: 201411-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: 20357
Title: Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges (CMS-10371)
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: 05/27/2015
	Date Received in OIRA: 04/24/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2018	36 Months From Approved	05/31/2015
Responses	1,080	0	860
Time Burden (Hours)	30,731	0	64,140
Cost Burden (Dollars)	0	0	28,081

---

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.

---

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
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 5118	01/30/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 21721	04/20/2015
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 9

IC Title	Form No.	Form Name
Annual Report	CMS-10371, CMS-10371	Annual Report Template ,   Annual Reporting Data Elements
Monthly Reports	CMS-10371, CMS-10371	Monthly Progress Report ,   Monthly Progress Report Data Elements
Weekly Reports	CMS-10371	Weekly Report
Semi-Annual Reports	CMS-10371	Establishment Review - Semi-Annual
Implementation Review	CMS-10371	Exchange Establishment Grant FOA
Application	CMS-10371	Revised FOA
Performance Reviews	CMS-10371	Revised FOA ,   Revised FOA
Budget Report	CMS-10371	Budget Report
Periodic Reporting	CMS-10371	Revised FOA
Start-Up Year Establishment Review
Public - Progress Reports	CMS-10371, CMs-10371	Progress Report ,   Progress Report
Work Plan Update	CMS-10371	Establishment Review - Work Plan Update
Quarterly Reports	CMS-10371	Quarterly Template

---

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	1,080	860	0	0	220	0
Annual Time Burden (Hours)	30,731	64,140	0	0	-33,409	0
Annual Cost Burden (Dollars)	0	28,081	0	0	-28,081	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 ICR revision deletes the requirements for the application as there are no further funds being awarded under this program. It also deletes separate planning and design reviews, and creates a single multi-faceted Implementation Review that encompasses examination of the design, implementation and effectiveness of each Marketplace's infrastructure and processes required for effective performance. As a result, there is a total reduction of 33,409 burden hours.

---

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

---

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: 04/24/2015

---