Consumer Operated and Oriented Plan [CO-OP] Program (CMS-10392)

Forms and Documents

Document	Type	Status	Availability
Form CMS-10392 Updated Business Plans	Form and Instruction	Modified	Repair queued
Form CMS-10392 Core Contracts	Form and Instruction	Unchanged	Repair queued
Form CMS-10392 Disbursement Requests	Form and Instruction	Unchanged	Available
Form CMS-10392 Request for additional funding	Form and Instruction	Modified	Repair queued
Form CMS-10392 Recordkeeping	Form and Instruction	Unchanged	Repair queued
Form CMS-10392 Audits	Form and Instruction	Unchanged	Available
Form CMS-10392 Enhanced Reporting (Before Loan Repayment) - Start-up/Solvency Loan Recipients	Form and Instruction	Modified	Available
Form CMS-10392 Standard Reporting After Loan Repayment - Start-up/Solvency Loan Recipients	Form and Instruction	Modified	Available
Form CMS-10392 Standard Reporting Before Loan Repayment - Start-up/Solvency Loan(s) Recipients	Form and Instruction	Modified	Available
Form CMS-10392 Loan Agreement Acceptance	Form and Instruction	Unchanged	Available
Form CMS-10392 Reconsiderations & Appeals	Form and Instruction	Unchanged	Available
Form CMS-10392 Start-up & Solvency Loan Application	Form and Instruction	Unchanged	Repair queued
CMS-10392 - PRA Comments and Response 5-29-15 v2.doc	Supplementary Document	Uploaded 2015-05-29	Repair queued
CMS-10392 - Crosswalk 033015.xls	Supplementary Document	Uploaded 2015-04-27	Available
CMS-10392 - Supporting Statement 04012015 FINAL.pdf	Supporting Statement A	Uploaded 2015-04-27	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
214075	Updated Business Plans	Form and Instruction	Modified
214074	Core Contracts	Form and Instruction	Unchanged
214072	Disbursement Requests	Form and Instruction	Unchanged
214020	Request for additional funding	Form and Instruction	Modified
198657	Recordkeeping	Form and Instruction	Unchanged
198656	Audits	Form and Instruction	Unchanged
198655	Enhanced Reporting (Before Loan Repayment) - Start-up/Solvency Loan Recipients	Form and Instruction	Modified
198654	Standard Reporting After Loan Repayment - Start-up/Solvency Loan Recipients	Form and Instruction	Modified
198653	Standard Reporting Before Loan Repayment - Start-up/Solvency Loan(s) Recipients	Form and Instruction	Modified
198652	Loan Agreement Acceptance	Form and Instruction	Unchanged
198651	Reconsiderations & Appeals	Form and Instruction	Unchanged
198650	Start-up & Solvency Loan Application	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0938-1139	ICR Reference No: 201504-0938-015
Status: Historical Active	Previous ICR Reference No: 201411-0938-013
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Consumer Operated and Oriented Plan [CO-OP] Program (CMS-10392)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/29/2015
	Date Received in OIRA: 04/28/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2018	36 Months From Approved	01/31/2018
Responses	802	0	710
Time Burden (Hours)	93,320	0	89,272
Cost Burden (Dollars)	0	0	0

---

Abstract: The data collection in this package includes requirements associated with the Consumer Operated and Oriented Plan [CO-OP] Program, which includes Loan applications; Reconsideration requests and appeals; Loan Agreement acceptance and execution; Milestone updates; Financial reports; Progress reports; Enhanced financial and progress reports; Audits; and Recordkeeping.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 1322 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 112 - 240 644 Name of Law: American Taxpayer Relief Act of 2012

---

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 23011	04/24/2015
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Loan Agreement Acceptance	CMS-10392	CO-OP FOA
Disbursement Requests	CMS-10392	CO-OP FOA
Core Contracts	CMS-10392	CO-OP FOA
Updated Business Plans	CMS-10392, CMS-10392, CMS-10392	CO-OP FOA ,   Project Plan without Resources ,   Project Plan with Resources
Start-up & Solvency Loan Application	CMS-10392	CO-OP FOA
Reconsiderations & Appeals	CMS-10392	CO-OP FOA
Standard Reporting Before Loan Repayment - Start-up/Solvency Loan(s) Recipients	CMS-10392, CMS-10392	Reporting Templates ,   CO-OP FOA
Standard Reporting After Loan Repayment - Start-up/Solvency Loan Recipients	CMS-10392, CMS-10392	Reporting Templates ,   CO-OP FOA
Enhanced Reporting (Before Loan Repayment) - Start-up/Solvency Loan Recipients	CMS-10392, CMS-10392, CMS-10392, CMS-10392, CMS-10392, CMS-10392	Reporting Templates ,   CO-OP FOA ,   Monthly Reporting Guidance ,   Monthly Reporting Template ,   Semi-Annual Reporting Template ,   Quarterly Financial Report
Audits	CMS-10392	CO-OP FOA
Recordkeeping	CMS-10392	CO-OP FOA
Request for additional funding	CMS-10392	CO-OP FOA

---

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	802	710	0	92	0	0
Annual Time Burden (Hours)	93,320	89,272	0	4,048	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: CO-OPs are required to provide annual pro forma financial projections to CMS on March 1. At CMS's discretion, the pro forma financial projections may be requested on a semi-annual basis. The guidance for this is included in the semi-annual reporting tool which is submitted to CMS on March 1 and August 15. Pro forma financial projections aid CMS in determining whether a CO-OP is a financial risk. As the lender to the CO-OPs, CMS has a vested interest in a given CO-OP's financial viability. As such, we are requiring an additional reporting requirement to collect pro forma financial projections (including monthly cash flow projections for 18 months from the date of submission) on a quarterly basis. Furthermore, CMS is amending the monthly reporting guidance to clarify current requirements and include additional data elements necessary for CMS to conduct appropriate oversight over the CO-OP program. The additional quarterly reporting requirements will increase the total burden from 89,272 hours annually to 93,320 hours annually. Please note that there is no change in the burden for the additional data elements in the monthly reporting requirements as this information is readily available to the CO-OPs on a monthly basis.

---

Annual Cost to Federal Government: $623,949

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: 04/28/2015

---