CMS- 10440 Supporting Statement 30 Day Clean

Supporting Statement for Data Collection to Support Eligibility
Determinations for Insurance Affordability Programs and Enrollment
through Health Insurance Marketplaces, Medicaid, and
Children’s Health Insurance Program Agencies
A. Background
On March 23, 2010, the President signed into law H.R. 3590, the Patient Protection and
Affordable Care Act, Public Law 111-148, as amended by the Health Care and Education
Reconciliation Act of 2010, Pub. L. 111-152, collectively referred to as “The Affordable Care
Act.” The Affordable Care Act expands access to health insurance coverage through the
establishment of Health Insurance Marketplaces, also known as Affordable Insurance
Exchanges, improvements to the Medicaid and Children’s Health Insurance (CHIP) programs,
and the assurance of coordination between Medicaid, CHIP, and Marketplaces.
Marketplaces established by the Affordable Care Act facilitate the enrollment of qualified
individuals into Qualified Health Plans (QHPs). Section 1401 of the Affordable Care Act created
a new section 36B of the Internal Revenue Code (the Code), which provides for a premium tax
credit which is available on an advanced basis (“Advance Payments of the Premium Tax Credit”
or APTC) to reduce the monthly insurance costs for eligible individuals who enroll in a QHP
through a Marketplace. In addition, section 1402 of the Affordable Care Act establishes
provisions to reduce cost-sharing obligations, including copayments and deductibles, of eligible
individuals enrolled in a QHP offered through a Marketplace (“Cost-Sharing Reductions” or
CSRs).
The Affordable Care Act also fills current gaps in coverage by creating a minimum Medicaid
income eligibility level across the country and by simplifying the current eligibility rules in the
Medicaid and CHIP programs. Under the Affordable Care Act, in states that have chosen to
expand Medicaid for adults, most individuals under 65 with income below 133 percent of the
Federal Poverty Level (FPL) may be eligible for Medicaid since January 2014.
As required under section 1413 of the Affordable Care Act, there is one application through
which individuals may apply for Marketplace QHPs with or without APTC and CSRs, Medicaid,
and CHIP and receive an eligibility determination.
CMS developed this Paperwork Reduction Act (PRA) package as part of an effort to solicit
feedback from key stakeholders on the electronic and paper applications. This package provides
details on the proposed collection of information from the public to facilitate providing eligibility
for coverage and assistance in enrolling in a QHP or Medicaid and CHIP programs across the
Marketplaces. Please note, we provide examples of how this information is collected in an
electronic fashion via multiple channels and in a paper-based format. This PRA questionnaire
serves as the foundation for supporting a consumer’s ability to apply for and enroll in a
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Marketplace QHP or Medicaid & CHIP coverage in any FFM or SBM state. Further discussion
of stakeholder consultation can be found in section B8.
B. Justification
1. Need and Legal Basis
Section 1413 of the Affordable Care Act directs the Secretary of Health and Human Services to
develop and provide to each state a single, streamlined application form that may be used to
apply for coverage through a Marketplace and for APTC/CSR, Medicaid, and CHIP (which we
refer to collectively as insurance affordability programs). The application must be structured to
maximize an applicant’s ability to complete the form satisfactorily, taking into account the
characteristics of individuals who may qualify for the programs by developing materials at
appropriate literacy levels and ensuring accessibility. A state may develop and use its own
application if approved by the Secretary in accordance with section 1413 and if it meets the
standards established by the Secretary.
45 CFR §155.405(a) provides more detail about the application that must be used by
Marketplaces to determine eligibility and to collect information necessary for
enrollment. Eligibility standards for the Marketplace are set forth in 45 CFR §155.305. The
information will be required of each applicant upon initial application, with some subsequent
information collections for the purposes of confirming accuracy of previous submissions and for
changes in an applicant’s circumstances. 42 CFR §§435.907 and 457.330 establish the standards
for state Medicaid and CHIP agencies related to the use of the application. CMS has designed a
dynamic electronic application that will tailor the amount of data required from an applicant
based on the applicant’s circumstances and responses to particular questions in the FFM (please
note SBM implementations may vary but the essence of the data collection must adhere to the
same parameters). The paper version of the application will not be tailored in the same way but
will require only the data necessary to determine eligibility.
The Affordable Care Act directs that Marketplaces permit individuals to apply for coverage
during annual open enrollment. Individuals may apply outside of the open enrollment periods,
and enroll in coverage right away if they qualify for a special enrollment period (outlined in 45
CFR §155.420(d)). Medicaid and CHIP do not have specified open enrollment periods. The
application will be available at all times during the year.
Individuals will be able to submit an application electronically, through the mail, over the phone
through a call center, or in person, per 45 CFR §155.405(c)(2), as well as through other
commonly available electronic means as noted in 42 CFR §435.907(a) and §457.330. The
application may be submitted to a Marketplace, Medicaid or CHIP agency.

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We have included the following attachments of application materials to illustrate the process
applicants will use to apply for health coverage in a qualified health plan through a Marketplace
and for insurance affordability programs.
•

Attachment A: List of Items in the Electronic Application to Support Eligibility
Determinations for Enrollment through the Marketplace and for Medicaid and the
Children’s Health Insurance Program – a list of all potential questions that could be
asked on the electronic application. No applicant will ever be required to answer this
exhaustive list of questions; the vast majority of applicants will be asked less than onethird of these questions. The document includes descriptions of question logic and skip
patterns.

•

Attachment A-1: Additional Electronic Application Items to Support Eligibility
Determinations for Enrollment through the Health Insurance Marketplace and for
Medicaid and the Children’s Health Insurance Program – a list of additional questions to
guide consumer to the most appropriate application for their household characteristics
and interests.

•

Attachment B: Application for Health Coverage & Help Paying Costs (Short Form) –
this paper application can be used by some single individuals to receive an eligibility
determination for enrollment through the Marketplace or for Medicaid and the
Children’s Health Insurance Program. This application can be used by single individuals
who: do not have any dependent children and are not claimed as a dependent on
someone else’s tax return; are not American Indian/Alaska Native; are not offered
coverage through a job; were not in the foster care system (and under age 26); and do not
deduct certain expenses from his/her income. Otherwise, individuals should apply online
or use Attachment C. The short form is also accompanied by Appendix C “Assistance
with Completing this Application.”

•

Attachment C: Application for Health Coverage & Help Paying Costs – this paper
application supports eligibility determinations for enrollment through the Marketplace or
for Medicaid or CHIP. The application can be used to determine eligibility for an
individual or family applying for enrollment through the Marketplace, Advance Payment
of the Tax Credit, cost-sharing reductions, Medicaid and CHIP. The Application for
Health Coverage & Help Paying for Costs is also accompanied by 1) Appendix A
“Health Coverage from Jobs and Employer Coverage Tool,” designed to assist
consumers to gather necessary information to answer employer sponsored health
coverage questions on the application; 2) Appendix B “American Indian or Alaska
Native Family Member (AI/AN)”; and 3) Appendix C “Assistance with Completing this
Application.”

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•

Attachment D: Application for Health Coverage – this paper application supports
eligibility determinations for enrollment through the Marketplace for applicants who do
not wish to be considered for insurance affordability programs. The application can be
used to determine eligibility for an individual or family applying to directly purchase
QHP coverage through a QHP through the Marketplace. This implementation of
application questions in this form is less burdensome for consumers who do not wish to
be considered for insurance affordability program eligibility. The application for health
coverage is also accompanied by Appendix C “Assistance with Completing this
Application.”

•

Attachment E: This is a summary of the 60-day comments received and CMS responses.

•

Attachment F: This is a crosswalk of the changes made in response to the 60-day
comments to Attachments A and A1.

2. Information Users
Information collected by the Marketplace, Medicaid, or CHIP agency will be used to determine
eligibility for coverage through the Marketplace and insurance affordability programs and assist
consumers in enrolling in a QHP if eligible. Applicants include anyone who may be eligible for
coverage through any of these programs.
3. Use of Information Technology
Technology enables the electronic application process to offer a number of advantages over a
paper application process. The electronic application will feature a dynamic or “smart” process
that poses questions to the applicant based on the responses to previous questions and available
verification of information. This ensures that only relevant questions are asked and any nonrelevant questions are not displayed (for example, the electronic application does not ask men if
they are pregnant). The paper application does not offer the same flexibility in customizing the
sequence or number of questions. The electronic application will also be able to catch
inadvertent errors in real time, as well as immediately verify information in many cases. The
electronic process will be designed to allow individuals to save information through a unique
user account, obtain access to immediate help resources, and more quickly enroll in coverage. As
compared to applying via paper, the electronic application will allow applicants to complete the
process more efficiently and receive an eligibility determination more quickly. Therefore the
electronic application will reduce the burden of applying for coverage.
4. Duplication of Effort
This information collection does not duplicate any other effort, and we will make every effort to
obtain such information from existing sources.
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5. Small Businesses
Small businesses are not affected by this data collection.
6. Consequences of Less Frequent Collection
The Affordable Care Act directs that Marketplaces permit individuals to apply for coverage
during annual open enrollment periods and during special enrollment periods, when applicable.
Additionally, individuals may apply for Medicaid and CHIP at any time throughout the year. If
information was collected less frequently or not at all, individuals would not be able to gain
coverage under Affordable Care Act reforms and the program would be unable to operate.
7. Special Circumstances that may cause respondents to submit information in fewer than 30
days
An individual who is enrolled in a QHP through a Marketplace is required to report changes that
impact eligibility to the Marketplace within 30 days of such a change per 45 CFR §155.330(b).
Individuals are required to report changes in residency, incarceration, household makeup,
income, and citizenship or lawful presence. The Marketplace may conduct a redetermination for
eligibility to be enrolled in a QHP based on the reported change.
If an individual is responding by mail to a request for follow up regarding an application, for
example, the individual may need to respond in fewer than 30 days if the open enrollment period
will end in less than 30 days, or if it is the policy of the Medicaid or CHIP agency.
8. Federal Register/Outside Consultation
As required by the Paperwork Reduction Act of 1995 (44 U.S.C.2506 (c)(2)(A)), CMS published
the Application PRA package for a 60-day comment period in the Federal Register on December
2, 2015, ending on February 1, 2016 (80 FR 75463). This 30-day posting reflects proposed
changes made to the data collection for the online electronic application and screener
(Attachment A and Attachment A-1) in response to public comments received from the 60-day
comment period. The comments have been summarized and addressed in the comment/response
document (Attachment E of the 30-day ICR submission). The paper applications (Attachments
B, C and D) will be updated prior to Open Enrollment each year to reflect the appropriate content
for the coverage year.
9. Payments/Gifts to Respondents
There are no payments or gifts to respondents.
10. Confidentiality
All information will be kept private pursuant to applicable laws/regulations.
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11. Sensitive Questions
Per statute, a Social Security number and information about citizenship or immigration status are
needed to help verify eligibility for coverage. The items in this collection are included in the
SORN (09-70-0560) published in the Federal Register on February 6, 2013.
12. Estimates of Annualized Burden Hours
The Congressional Budget Office (CBO) estimated in March 2015 that approximately 24 million
people will enroll in coverage through the Marketplaces and insurance affordability programs per
year from 2017 to 2019. 1 CMS estimates an average of 30% of those enrolled represents new
enrollments (equally about 7,200,000 per year) as the base population of the remaining uninsured
continues to decrease so will the take-up rate among eligible insured individuals. Leveraging
data reported by the Department of Health and Human Services (HHS) Office of the Assistant
Secretary for Planning and Evaluation (ASPE) based on the 2015 Open enrollment period 2, CMS
estimates that 74% of the new enrollment represents the total number of new applications that
need to be accounted for in this collection as a single completed application can include multiple
individual applicants from the same household.
Therefore, CMS expects a total of 5,328,000 new applications a year from 2017 to 2019,
resulting in a total of 2,410,767 total burden hours each year. Further, CMS estimates that
approximately 90% of consumers will submit online applications.
Burden for Electronic Application
CMS estimates that the electronic application process will vary depending on each applicant’s
circumstances, their experience with health insurance applications and electronic capabilities.
The goal is to solicit sufficient information so that in most cases no further inquiry will be
needed. In addition, online channels will administer an identification proofing process prior to
the electronic eligibility application information. Based on the information an individual
provides, the identification proofing system will generate a series of challenge questions, such as
a previous address where an individual has lived. The system will have a large bank of questions
it will randomly generate based on information from external databases. To protect the security
and integrity of the system, we cannot provide the list of questions generated. Additional burden
from the identification proofing process is negligible in the context of the electronic application
questions. Please refer to Attachment A for the placement of and more detail about the
identification proofing process. We estimate that on average it will take approximately 30
minutes (0.50 hours) to complete an application for insurance affordability programs. It will take

1 Effects of the Affordable Care Act on Health Insurance Coverage – Baseline Projections, CBO, March 2015.
2 Health Insurance Marketplaces 2015 Open Enrollment Period: March Enrollment Report, ASPE, March 2015.
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an estimated 15 minutes (0.25 hours) to complete an application without consideration for
insurance affordability programs.
CMS estimates that approximately 4,795,200 new electronic applications will be submitted for
Marketplace and insurance affordability programs each year from 2017 through 2019 for a total
number of 2,129,468 yearly burden hours.
Burden for Paper Application
CMS estimates that the paper application process will take an average of 45 minutes (0.75 hours)
to complete for those applying for insurance affordability programs; 15 minutes (0.25 hours) for
those applying for insurance affordability programs using the short form; and 20 minutes (0.33
hours) for those applying without consideration for insurance affordability programs.
CMS further estimates that approximately 532,800 paper applications will be submitted for
Marketplace insurance affordability programs for the next three years. One third of respondents
will complete the short form and two-thirds will complete the longer form, resulting in 281,299
total burden hours a year from 2017-2019.
Application Processing Burden
Marketplaces and state Medicaid and/or CHIP agencies will need to process applications and
make eligibility determinations based on the information submitted from individuals. CMS
estimates the burden to be 10 minutes (0.17 hours) for online applications and 30 minutes (0.50
hours) for paper applications at a rate of $27 per hour. 3 The table below shows the estimated
processing costs associated with this program.
Table 4: Application Processing Costs
Application
Type

Electronic
Application

Number of
Respondents
(a)

4,795,200

Burden per
Response
(hours)
(b)

Total
Annual
Burden
(hours)
(c)
(a) x (b)

0.17

815,184

Labor Costs
(per hour)
(d)

$27.00

Total Cost
(e)
(c) x (d)

$22,009,968

3 Occupational Employment Statistics survey results for “43-4061 Eligibility Interviewers, Government Programs”,
May 2014.
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Application
Type

Number of
Respondents
(a)

Paper
Application

532,800

Total

5,328,000

Burden per
Response
(hours)
(b)

Total
Annual
Burden
(hours)
(c)
(a) x (b)

0.5

266,400

Labor Costs
(per hour)
(d)

$27.00

1,081,594

Total Cost
(e)
(c) x (d)

$7,192,800

$29,202,769

12A. Estimated Annualized Burden Hours

Table 1: Estimated Burden Table, Average
Application
Type

Type of
Respondent

Number of
New
Respondents
(a)

Number of
Responses
per
Respondent

Average
Burden
Hours per
Response
(b)

Total Burden
Hours
(c)
(a) x (b)

Online
Application

Applying for
insurance
affordability
programs

3,722,670

1

0.5

1,861,335

Online
Application

Not applying for
insurance
affordability
programs

1,072,530

1

0.25

268,133

Paper
Application

Applying for
insurance
affordability
programs

277,132

1

0.75

207,849

Paper
Application

Applying for
insurance
affordability
programs (Short
Form)

136,498

1

0.25

34,124

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Application
Type

Paper
Application

Type of
Respondent

Not applying for
insurance
affordability
programs

Total

Number of
New
Respondents
(a)

119,170

Number of
Responses
per
Respondent

1

Average
Burden
Hours per
Response
(b)
0.33

5,328,000

Total Burden
Hours
(c)
(a) x (b)

39,326

2,410,767

13. Capital Costs
There are no additional capital costs.
14. Cost to Federal Government
The collection’s burden to the federal government includes maintaining the application and
implementation of the data. The overall cost is estimated to be $295,772. This estimate projects
software development costs at $98.50 an hour and assumes approximately 13 weeks of
development.
Table 3: Cost to federal government to maintain application
Data Collection and
Development Task

Application
Development

Number of
Developer Hours
(a)

Average
Labor Cost
Per Hour (b)

2,080

$98.50

Cost of Development
(c)
(a) x (b)
$204,880

1 GS-13 FTE (as COR)

$90,892

Total

$295,772

An additional burden to the federal government is the work of one full time GS-13 employee to
serve as the COR for an application contract. The current (2015) salary of a 13 Grade/Step 1
employee in the Washington, D.C. area is $90,892.

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15. Changes to Burden
While a couple additional questions were added in response to comments received from the 60
day posting, none were substantial enough to warrant changes to burden estimates. The changes
modified language for an attestation and optional questions.
OMB previously approved this information collection in April, 2013 with a total of 3,035,434
responses and 1,428,822 burden hour. There have been no interim approvals.
For this renewal, CMS estimates that the total new responses (applications) will be 5,328,000 per
year and the total burden hours will be 2,410,767 per year. This reflects an increase of 2,292,566
responses and 981,945 total burden hours per year from the currently approved burden for this
collection.
Changes in Application Processing Cost Burden
For this renewal, CMS estimates that the total annual application cost burden will decrease by
$20,708,891 (from $49,911,660 per year to $29,202,769 per year) due to administrative
adjustments.
16. Publication/Tabulation Dates
Not applicable.
17. Expiration Date
CMS would like an exemption from displaying the expiration date as these forms are used on a
continuing basis. To include an expiration date would result in having to discard a potentially
large number of forms that are otherwise usable, creating unnecessary waste and cost burden.

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