Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel (CAC)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10494 Recertification Request Form	Form and Instruction	New	Repair queued
Form CMS-10494 Find Local Help Instrument	Form and Instruction	New	Repair queued
Form CMS-10494 Training Quality Questionnaire	Form and Instruction	New	Available
Form CMS-10494 Registration	Form and Instruction	Modified	Repair queued
Form CMS-10494 Registration	Form and Instruction	Modified	Available
Form CMS-10494 Registration	Form and Instruction	Unchanged	Available
Form CMS-10494 Registration	Form and Instruction	Unchanged	Available
Form CMS-10494 Registration Portal	Form and Instruction	Modified	Available
Form CMS-10494 Model Authorization Form (Spanish)	Form and Instruction	Modified	Available
Form CMS-10494 Model Authorization Form (English)	Form and Instruction	Modified	Available
Form CMS-10494 CAC Agreement	Form and Instruction	Modified	Available
Form CMS-10494 Sample Certification Certificate (Spanish)	Form and Instruction	Modified	Available
Form CMS-10494 Training Certificate (English)	Form and Instruction	Modified	Available
Form CMS-10494 Training Certificate	Form and Instruction	Modified	Repair queued
Form CMS-10494 CAC Organization Application	Form and Instruction	Modified	Repair queued
Form CMS-10494 Individual CAC Agreement	Form and Instruction	Modified	Available
CMS-10494-Supporting Statement Part A-PRA amendment for OMB 0938-1205 4 6 15 CLEAN 508MM.pdf	Supporting Statement A	Uploaded 2015-04-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
216275	Recertification Training		New
216274	Recertification request by organization	Form and Instruction	New	Recertification Request Form
216273	CAC Recertification		New
216272	155.225(b)(1) Organization designation by Exchange Information Updates	Form and Instruction	New	Find Local Help Instrument
216271	155.225(d)(1) and (7) Training Quality Optional Questionnaire	Form and Instruction	New	Training Quality Questionnaire
208217	155.225(d)(1) - Training certificate retention	Form and Instruction	Modified	Registration
208216	155.225(d)(1) - Training certificate proof	Form and Instruction	Modified	Registration
208215	155.225(d)(1) - Training Registration	Form and Instruction	Unchanged	Registration
208214	155.225(b)(1)(ii) - Identification number record retention	Form and Instruction	Unchanged	Registration
208213	155.225(b)(1)(ii) - Issuance of unique registration identification number	Form and Instruction	Modified	Registration Portal
207940	155.225(d)(2) and (f) (CAC authorization to consumer)	Form and Instruction	Modified	Model Authorization Form (Spanish)
207940	155.225(d)(2) and (f) (CAC authorization to consumer)	Form and Instruction	Modified	Model Authorization Form (English)
207940	155.225(d)(2) and (f) (CAC authorization to consumer)	Form and Instruction	Modified	CAC Agreement
207939	155.225(d)(2) and (f) (organization record of authorization)		Modified
207938	155.225(b)(1)(i) (certificate issuance)	Form and Instruction	Modified	Sample Certification Certificate (Spanish)
207938	155.225(b)(1)(i) (certificate issuance)	Form and Instruction	Modified	Training Certificate (English)
207938	155.225(b)(1)(i) (certificate issuance)	Form and Instruction	Modified	Training Certificate
207937	155.225(b)(1) (organization list)		Modified
207874	155.225(b)(1)(i) (organization attestation)		Modified
207873	155.225(b)(1) (organization follow-up for application)	Form and Instruction	Modified	CAC Organization Application
207872	155.225(b)(1) (organization designation by Exchange)	Form and Instruction	Modified	Individual CAC Agreement

ICR Details

OMB Control No: 0938-1205	ICR Reference No: 201504-0938-012
Status: Historical Active	Previous ICR Reference No: 201308-0938-016
Agency/Subagency: HHS/CMS	Agency Tracking No: 20316
Title: Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel (CAC)
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
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/24/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2018	36 Months From Approved	08/31/2016
Responses	4,676,018	0	4,596,000
Time Burden (Hours)	693,701	0	667,740
Cost Burden (Dollars)	0	0	0

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Abstract: Section 1413 of the Affordable Care Act directs the Secretary of HHS to establish, subject to minimum requirements, a streamlined enrollment system for qualified health plans offered through the Exchange and insurance affordability programs. In addition, section 1321(a)(1) of the Affordable Care Act directs and authorizes the Secretary to issue regulations setting standards for meeting the requirements under title I of the Affordable Care Act, with respect to, among other things, the establishment and operation of Exchanges. Pursuant to this authority, regulations establishing the certified application counselor program are being finalized at 45 CFR 155.225. Specifically, 45 CFR 155.225(a) requires an Exchange to establish a certified application counselor program that complies with the requirements of the rule. Section155.225(b)(1) allows each Exchange to designate certain organizations, including organizations designated by state Medicaid or CHIP agencies, which will certify their staff and volunteers to act as certified application counselors. In accordance with 45 CFR 155.225(b)(2), Exchanges may choose to certify directly individuals who seek to act as certified application counselors, designate certain organizations which will certify staff or volunteers to perform application services, or do both.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1321(a)(1)(A) and (D) Name of Law: State Flexibility in Operation and Enforcement of Exchanges and Related Requirements
   PL: Pub.L. 111 - 148 1413 Name of Law: Streamlining of procedures for enrollment through an exchange
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1321(A) and (D) Name of Law: State Flexibility in Operation and Enforcement of Exchanges and Related Requirements
PL: Pub.L. 111 - 148 1413 Name of Law: Streamlining of procedures for enrollment through an exchange

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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:
	80 FR 5118	01/30/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 21721	03/31/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 17

table that charts list of burden

IC Title	Form No.	Form Name
155.225(b)(1) (organization designation by Exchange)	CMS-10494	Individual CAC Agreement
155.225(b)(1) (organization follow-up for application)	CMS-10494	CAC Organization Application
155.225(b)(1) (organization list)
155.225(b)(1) Organization designation by Exchange Information Updates	CMS-10494	Find Local Help Instrument
155.225(b)(1)(i) (certificate issuance)	CMS-10494, CMS-10494, CMS-10494	Training Certificate ,   Training Certificate (English) ,   Sample Certification Certificate (Spanish)
155.225(b)(1)(i) (organization attestation)
155.225(b)(1)(ii) - Identification number record retention	CMS-10494	Registration
155.225(b)(1)(ii) - Issuance of unique registration identification number	CMS-10494	Registration Portal
155.225(d)(1) - Training Registration	CMS-10494	Registration
155.225(d)(1) - Training certificate proof	CMS-10494	Registration
155.225(d)(1) - Training certificate retention	CMS-10494	Registration
155.225(d)(1) and (7) Training Quality Optional Questionnaire	CMS-10494	Training Quality Questionnaire
155.225(d)(2) and (f) (CAC authorization to consumer)	CMS-10494, CMS-10494, CMS-10494	CAC Agreement ,   Model Authorization Form (English) ,   Model Authorization Form (Spanish)
155.225(d)(2) and (f) (organization record of authorization)
CAC Recertification
Recertification Training
Recertification request by organization	CMS-10494	Recertification Request Form

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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	4,676,018	4,596,000	0	0	80,018	0
Annual Time Burden (Hours)	693,701	667,740	0	0	25,961	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 revised collection increased the total time burden by 11,350 hours. There are no changes in the labor costs rates. The change in burden is associated with making updates and changes to the information posted about designated organizations on the CMS public-facing website, completion of the optional training quality questionnaire at the end of the initial certification, and annual recertification, trainings. The questionnaire is optional, therefore actual increases in time and cost burdens may be lower. In addition, 14,611 were inadvertedly removed during the last approval. The hours are associated with recertification of training and should remain active.

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Annual Cost to Federal Government: $933

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: 04/24/2015

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