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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10494 Training Completion Document	Form	New	Repair queued
Form CMS-10494 Post-Training Questionnaire	Form and Instruction	New	Repair queued
Form CMS-10494 CDO Agreement	Form and Instruction	Unchanged	Available
Form CMS-10494 Certified Counselor Designated Organization (CDO Application)	Form and Instruction	Unchanged	Available
Form CMS-10494 Recertification Request Form	Form and Instruction	Unchanged	Available
Form CMS-10494 Recertification request by organization	Form and Instruction	Unchanged	Repair queued
Form CMS-10494 Find Local Help Instrument	Form and Instruction	Unchanged	Available
Form CMS-10494 155.225(b)(1) Organization designation by Exchange Information Updates	Form and Instruction	Unchanged	Repair queued
Form CMS-10494 Training Quality Questionnaire	Form and Instruction	Unchanged	Available
Form CMS-10494 155.225(d)(1) and (7) Training Quality Optional Questionnaire	Form and Instruction	Unchanged	Repair queued
Form CMS-10494 Registration	Form and Instruction	Unchanged	Available
Form CMS-10494 155.225(d)(1) - Training certificate retention	Form and Instruction	Unchanged	Repair queued
Form CMS-10494 Registration	Form and Instruction	Unchanged	Repair queued
Form CMS-10494 155.225(d)(1) - Training certificate proof	Form and Instruction	Unchanged	Repair queued
Form CMS-10494 Registration	Form and Instruction	Unchanged	Available
Form CMS-10494 155.225(d)(1) - Training Registration	Form and Instruction	Unchanged	Repair queued
Form CMS-10494 Registration	Form and Instruction	Unchanged	Available
Form CMS-10494 155.225(b)(1)(ii) - Identification number record retention	Form and Instruction	Unchanged	Repair queued
Form CMS-10494 Registration Portal	Form and Instruction	Unchanged	Available
Form CMS-10494 155.225(b)(1)(ii) - Issuance of unique registration identification number	Form and Instruction	Unchanged	Repair queued
Form CMS-10494 Model Authorization Form (Spanish)	Form and Instruction	Unchanged	Available
Form CMS-10494 Model Authorization Form (English)	Form and Instruction	Unchanged	Available
Form CMS-10494 CAC Agreement	Form and Instruction	Unchanged	Available
Form CMS-10494 155.225(d)(2) and (f) (CAC authorization to consumer)	Form and Instruction	Unchanged	Repair queued
Form CMS-10494 Sample Certification Certificate (Spanish)	Form and Instruction	Unchanged	Available
Form CMS-10494 Training Certificate (English)	Form and Instruction	Unchanged	Available
Form CMS-10494 Training Certificate	Form and Instruction	Unchanged	Available
Form CMS-10494 155.225(b)(1)(i) (certificate issuance)	Form and Instruction	Unchanged	Repair queued
Form CMS-10494 CAC Organization Application	Form and Instruction	Unchanged	Available
Form CMS-10494 155.225(b)(1) (organization follow-up for application)	Form and Instruction	Unchanged	Repair queued
Form CMS-10494 Individual CAC Agreement	Form and Instruction	Modified	Available
Form CMS-10494 155.225(b)(1) (organization designation by Exchange)	Form and Instruction	Modified	Repair queued
CMS-10494.Supporting Statement Part A (10-29-21).docx	Supporting Statement A	Uploaded 2021-11-03	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
251934	Navigator Requirements for Training Certification	Form	New	Training Completion Document
251934	Navigator Requirements for Training Certification	Form and Instruction	New	Post-Training Questionnaire
241050	Certified Counselor Designated Organization (CDO Application)	Form and Instruction	Unchanged	CDO Agreement
241050	Certified Counselor Designated Organization (CDO Application)	Form and Instruction	Unchanged
241050	Certified Counselor Designated Organization (CDO Application)	Instruction	Unchanged
220357	§155.225 (b)(ii) (performance tracking form by organization)		Unchanged
220355	§155.225 (b)(ii) (reporting performance data by certified application counselor)		Unchanged
220354	§155.225 (b)(ii) (recordkeeping performance data by organization)		Unchanged
220353	§155.225 (b)(1)(iii)- (reporting by organizations)		Unchanged
220352	§155.225 (b)(1)(iii)- (review by State Exchange)		Unchanged
220351	§155.225(b)(1)(iii)-(review byFederally-facilitatedExchange)		Unchanged
216275	Recertification Training		Unchanged
216274	Recertification request by organization	Form and Instruction	Unchanged	Recertification Request Form
216274	Recertification request by organization	Form and Instruction	Unchanged
216273	CAC Recertification		Modified
216272	155.225(b)(1) Organization designation by Exchange Information Updates	Form and Instruction	Unchanged	Find Local Help Instrument
216272	155.225(b)(1) Organization designation by Exchange Information Updates	Form and Instruction	Unchanged
216271	155.225(d)(1) and (7) Training Quality Optional Questionnaire	Form and Instruction	Unchanged	Training Quality Questionnaire
216271	155.225(d)(1) and (7) Training Quality Optional Questionnaire	Form and Instruction	Unchanged
208217	155.225(d)(1) - Training certificate retention	Form and Instruction	Unchanged	Registration
208217	155.225(d)(1) - Training certificate retention	Form and Instruction	Unchanged
208216	155.225(d)(1) - Training certificate proof	Form and Instruction	Unchanged	Registration
208216	155.225(d)(1) - Training certificate proof	Form and Instruction	Unchanged
208215	155.225(d)(1) - Training Registration	Form and Instruction	Unchanged	Registration
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	Registration
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	Unchanged	Registration Portal
208213	155.225(b)(1)(ii) - Issuance of unique registration identification number	Form and Instruction	Unchanged
207940	155.225(d)(2) and (f) (CAC authorization to consumer)	Form and Instruction	Unchanged	Model Authorization Form (Spanish)
207940	155.225(d)(2) and (f) (CAC authorization to consumer)	Form and Instruction	Unchanged	Model Authorization Form (English)
207940	155.225(d)(2) and (f) (CAC authorization to consumer)	Form and Instruction	Unchanged	CAC Agreement
207940	155.225(d)(2) and (f) (CAC authorization to consumer)	Form and Instruction	Unchanged
207939	155.225(d)(2) and (f) (organization record of authorization)		Unchanged
207938	155.225(b)(1)(i) (certificate issuance)	Form and Instruction	Unchanged	Sample Certification Certificate (Spanish)
207938	155.225(b)(1)(i) (certificate issuance)	Form and Instruction	Unchanged	Training Certificate (English)
207938	155.225(b)(1)(i) (certificate issuance)	Form and Instruction	Unchanged	Training Certificate
207938	155.225(b)(1)(i) (certificate issuance)	Form and Instruction	Unchanged
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	Unchanged	CAC Organization Application
207873	155.225(b)(1) (organization follow-up for application)	Form and Instruction	Unchanged
207872	155.225(b)(1) (organization designation by Exchange)	Form and Instruction	Modified	Individual CAC Agreement
207872	155.225(b)(1) (organization designation by Exchange)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1205	ICR Reference No: 202110-0938-014
Status: Historical Active	Previous ICR Reference No: 201810-0938-013
Agency/Subagency: HHS/CMS	Agency Tracking No: CCIIO - 10494
Title: Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel - CAC (CMS-10494)
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: 03/02/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/03/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2025	36 Months From Approved	03/31/2024
Responses	4,858,068	0	4,858,018
Time Burden (Hours)	918,023	0	857,046
Cost Burden (Dollars)	0	0	0

---

Abstract: Section 1413 of the Affordable Care Act directs the Secretary of HHS to establish, subject to minimum requirements, a streamlined enrollment system for qualified health plans offered through the Exchange and insurance affordability programs. In addition, section 1321(a)(1) of the Affordable Care Act directs and authorizes the Secretary to issue regulations setting standards for meeting the requirements under title I of the Affordable Care Act, with respect to, among other things, the establishment and operation of Exchanges. Pursuant to this authority, regulations establishing the certified application counselor program are being finalized at 45 CFR 155.225. Specifically, 45 CFR 155.225(a) requires an Exchange to establish a certified application counselor program that complies with the requirements of the rule. Section155.225(b)(1) allows each Exchange to designate certain organizations, including organizations designated by state Medicaid or CHIP agencies, which will certify their staff and volunteers to act as certified application counselors. In accordance with 45 CFR 155.225(b)(2), Exchanges may choose to certify directly individuals who seek to act as certified application counselors, designate certain organizations which will certify staff or volunteers to perform application services, or do both.

---

Authorizing Statute(s): PL: Pub.L. 111 - 148 1321(a)(1)(A) and (D) Name of Law: State Flexibility in Operation and Enforcement of Exchanges and Related Requirements
   PL: Pub.L. 111 - 148 1413 Name of Law: Streamlining of procedures for enrollment through an exchange
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1321(A) and (D) Name of Law: State Flexibility in Operation and Enforcement of Exchanges and Related Requirements
PL: Pub.L. 111 - 148 1413 Name of Law: Streamlining of procedures for enrollment through an exchange

---

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:
	86 FR 32049	06/16/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 59165	10/26/2021
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 25

table that charts list of burden

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

---

ICR Summary of Burden

table that charts list 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	4,858,068	4,858,018	0	0	50	0
Annual Time Burden (Hours)	918,023	857,046	0	0	60,977	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: The burden increased from 857,046 hours to 918,023 hours due the added requirement for Navigator certification training. This change in burden is associated with restoring requirements related to certification training for Navigators that were inadvertently omitted from a previous information collection.

---

Annual Cost to Federal Government: $65,520

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

---

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: 11/03/2021

---