Information Collection Request

Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel -CAC (CMS-10494)

ICR 201603-0938-001 · OMB 0938-1205 · Historical Inactive

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-10494 Recertification request by organization Form and Instruction Modified Available
Form CMS-10494 155.225(b)(1) Organization designation by Exchange Information Updates Form and Instruction Modified Available
Form CMS-10494 155.225(d)(1) and (7) Training Quality Optional Questionnaire Form and Instruction Modified Available
Form CMS-10494 155.225(d)(1) - Training certificate retention Form and Instruction Unchanged Available
Form CMS-10494 155.225(d)(1) - Training certificate proof Form and Instruction Unchanged Available
Form CMS-10494 155.225(d)(1) - Training Registration Form and Instruction Unchanged Available
Form CMS-10494 155.225(b)(1)(ii) - Identification number record retention Form and Instruction Unchanged Available
Form CMS-10494 155.225(b)(1)(ii) - Issuance of unique registration identification number Form and Instruction Modified Available
Form CMS-10494 155.225(d)(2) and (f) (CAC authorization to consumer) Form and Instruction Modified Available
Form CMS-10494 155.225(b)(1)(i) (certificate issuance) Form and Instruction Modified Repair queued
Form CMS-10494 155.225(b)(1) (organization follow-up for application) Form and Instruction Modified Available
Form CMS-10494 155.225(b)(1) (organization designation by Exchange) Form and Instruction Modified Available
CMS-10494 - Appendix M Response_to_Public_Comments 508MM.PDF Supplementary Document Uploaded 2016-03-02 Available
CMS-10494 Supporting Statement Part B.pdf Supporting Statement B Uploaded 2016-03-01 Available
CMS-10494 Supporting Statement Rev15.doc Supporting Statement A Uploaded 2016-03-02 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
220357 ?155.225 (b)(ii) (performance tracking form by organization) New
220355 ?155.225 (b)(ii) (reporting performance data by certified application counselor) New
220354 ?155.225 (b)(ii) (recordkeeping performance data by organization) New
220353 ?155.225 (b)(1)(iii)- (reporting by organizations) New
220352 ?155.225 (b)(1)(iii)- (review by State Exchange) New
220351 ?155.225(b)(1)(iii)-(review byFederally-facilitatedExchange) New
216275 Recertification Training Modified
216274 Recertification request by organization Form and Instruction Modified
216273 CAC Recertification Unchanged
216272 155.225(b)(1) Organization designation by Exchange Information Updates Form and Instruction Modified
216271 155.225(d)(1) and (7) Training Quality Optional Questionnaire Form and Instruction Modified
208217 155.225(d)(1) - Training certificate retention Form and Instruction Unchanged
208216 155.225(d)(1) - Training certificate proof Form and Instruction Unchanged
208215 155.225(d)(1) - Training Registration Form and Instruction Unchanged
208214 155.225(b)(1)(ii) - Identification number record retention Form and Instruction Unchanged
208213 155.225(b)(1)(ii) - Issuance of unique registration identification number Form and Instruction Modified
207940 155.225(d)(2) and (f) (CAC authorization to consumer) Form and Instruction Modified
207939 155.225(d)(2) and (f) (organization record of authorization) Unchanged
207938 155.225(b)(1)(i) (certificate issuance) Form and Instruction Modified
207937 155.225(b)(1) (organization list) Unchanged
207874 155.225(b)(1)(i) (organization attestation) Unchanged
207873 155.225(b)(1) (organization follow-up for application) Form and Instruction Modified
207872 155.225(b)(1) (organization designation by Exchange) Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
05/31/2018 36 Months From Approved 05/31/2018
4,676,018 0 4,676,018
693,701 0 693,701
0 0 0





Reginfo record details
23
table that charts list of burden
IC Title Form No. Form Name
Recertification Training
155.225(d)(1) and (7) Training Quality Optional Questionnaire CMS-10494 Training Quality Questionnaire
155.225(b)(1) Organization designation by Exchange Information Updates CMS-10494 Find Local Help Instrument
CAC Recertification
Recertification request by organization CMS-10494 Recertification Request Form
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)(i) (organization attestation)
155.225(b)(1)(i) (certificate issuance) CMS-10494, CMS-10494, CMS-10494 Training Certificate ,   Training Certificate (English) ,   Sample Certification Certificate (Spanish)
155.225(d)(2) and (f) (organization record of authorization)
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(b)(1)(ii) - Issuance of unique registration identification number CMS-10494 Registration Portal
155.225(b)(1)(ii) - Identification number record retention CMS-10494 Registration
155.225(d)(1) - Training Registration CMS-10494 Registration
155.225(d)(1) - Training certificate proof CMS-10494 Registration
155.225(b)(1) (organization list)
155.225(d)(1) - Training certificate retention CMS-10494 Registration
§155.225(b)(1)(iii)-(review byFederally-facilitatedExchange)
§155.225 (b)(1)(iii)- (reporting by organizations)
§155.225 (b)(ii) (recordkeeping performance data by organization)
§155.225 (b)(ii) (reporting performance data by certified application counselor)
§155.225 (b)(ii) (performance tracking form by organization)
§155.225 (b)(1)(iii)- (review by State Exchange)



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