Information Collection

Agents/Broker Data Collection in Federally Facilitated Health Insurance Exchanges

IC 207074 under ICR 202207-0938-019 · OMB 0938-1204.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1204 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10464 Agents/Broker Data Collection in Federally Facilitated Health Insurance Exchanges	Form and Instruction
CMS-10464 Agent-Broker Appendix A Screenshot_508_07.20.22 CMS-10464 Agent-Broker Appendix A Screenshot_508_07.20.22.pdf	Form and Instruction
CMS-10464 Agent-Broker Appendix A Screenshot_508_07.20.22 CMS-10464 Agent-Broker Appendix A Screenshot_508_07.20.22.pdf	Form and Instruction

IC Title:

Agents/Broker Data Collection in Federally Facilitated Health Insurance Exchanges

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 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-10464	Agent-Broker Appendix A Screenshot_508_07.20.22	CMS-10464 Agent-Broker Appendix A Screenshot_508_07.20.22.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 64,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	64,000	12,000	52,000
Annual IC Time Burden (Hours)	15,360	-240	15,600
Annual IC Cost Burden (Dollars)	0	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.