Information Collection

ICRs Related to the Ability of States to Permit Agents and Brokers to Assist Qualified Individuals, Qualified Employers, or Qualified Employees Enrolling in Qualified Health Plans in the Federally-fac

IC 228026 under ICR 201708-0938-021 · OMB 0938-1349.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1349 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10650 ICRs Related to the Ability of States to Permit Agents and Brokers to Assist Qualified Individuals, Qualified Employers, or Qualified Employees Enrolling in Qualified Health Plans in the Federally-fac	Form and Instruction
CMS-10650 Appendix A: Data Elements for General Function of an Exc CMS-10650 - Appendix A - Agents and Brokers Appendix A.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

ICRs Related to the Ability of States to Permit Agents and Brokers to Assist Qualified Individuals, Qualified Employers, or Qualified Employees Enrolling in Qualified Health Plans in the Federally-fac

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 155.220

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10650	Appendix A: Data Elements for General Function of an Exchange	CMS-10650 - Appendix A - Agents and Brokers Appendix A.pdf		Yes	Yes	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,830

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	100,830	100,830
Annual IC Time Burden (Hours)	501,125	501,125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.