Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and CHIP Agencies (CMS-10440)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10440 Application for Health Coverage (no cost help)	Form and Instruction	Modified	Available
Form CMS-10440 Application for Health Coverage & Help Paying Costs	Form and Instruction	Modified	Available
Form CMS-10440 Application for Health Coverage & Help Paying Costs (Short Form)	Form and Instruction	Modified	Available
CMS-10440 Supporting Statement.60 Day_DACAf.docx	Supporting Statement A	Uploaded 2023-04-28	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
205692	Individual Application	Form and Instruction	Modified	Application for Health Coverage (no cost help)
205692	Individual Application	Form and Instruction	Modified	Application for Health Coverage & Help Paying Costs
205692	Individual Application	Form and Instruction	Modified	Application for Health Coverage & Help Paying Costs (Short Form)
205692	Individual Application	Instruction	Modified

ICR Details

OMB Control No: 0938-1191	ICR Reference No: 202304-0938-028
Status: Historical Inactive	Previous ICR Reference No: 202208-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: CCIIO
Title: Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and CHIP Agencies (CMS-10440)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 06/30/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/28/2023
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2025	36 Months From Approved	10/31/2025
Responses	4,884,000	0	4,884,000
Time Burden (Hours)	2,205,614	0	2,205,614
Cost Burden (Dollars)	0	0	0

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Abstract: Section 1413 of the Affordable Care Act directs the Secretary of HHS to develop and provide to each State a single, streamlined form that may be used to apply for coverage through the Exchange and Insurance Affordability Programs. A state may develop and use its own single streamlined application if approved by the Secretary in accordance with section 1413 and if it meets the standards established by the Secretary.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1413 Name of Law: Affordable Care Act
   PL: Pub.L. 111 - 152 1314 Name of Law: Health Care and Education Reconciliation Act of 2010
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 1413 Name of Law: Affordable Care Act
PL: Pub.L. 111 - 152 1341 Name of Law: Health Care and Education Reconciliation Act of 2010

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV23	Proposed rulemaking	88 FR 25313	04/26/2023

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Individual Application	CMS-10440, CMS-10440, CMS-10440	Application for Health Coverage & Help Paying Costs (Short Form) ,   Application for Health Coverage & Help Paying Costs ,   Application for Health Coverage (no cost help)

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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: There is a total burden hour increase of +197,100 hours (from 2,205,614 hours to 2,402,714 hours). The burden increase is due to the increase in the number of expected new applications (increased from 4,884,000 to 5,084,000) and an increase in the amount of time it will take assist newly eligible applicants with processing their applications.

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Annual Cost to Federal Government: $314,721

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

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Common Form ICR:  No

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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: 04/28/2023

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