Exchange Blueprint Application

Blueprint for Approval of Affordable State-based and State Partnership Insurance Exchanges

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1172 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10416 Exchange Blueprint Application Form and Instruction
CMS-10416 Blueprint for Approval of Affordable Healthcare Marketpl CMS-10416 - Blueprint Application.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Exchange Blueprint Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 153 45 CFR 155.157 42 CFR 431, 435, and 457 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10416	Blueprint for Approval of Affordable Healthcare Marketplaces	CMS-10416 - Blueprint Application.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	7	-24	31
Annual IC Time Burden (Hours)	221	-5,331	5,552
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.