Exchange Functions in the Individual Market: Eligibility Determinations for Exchange Participation and Insurance Affordability

Establishment of an Exchange by a State and Qualified Health Plans (CMS-10593)

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

IC Title:	Exchange Functions in the Individual Market: Eligibility Determinations for Exchange Participation and Insurance Affordability	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.310(g) 45 CFR 155.310(d)(3) 45 CFR 155.310(h) 45 CFR 155.302(a) 45 CFR 155.315(f) 45 CFR 155.410 45 CFR 155.355(c) 45 CFR 155.345

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 23	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	23	23
Annual IC Time Burden (Hours)	15,063	15,063
Annual IC Cost Burden (Dollars)	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.