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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.