Information Collection

Application to State Exchanges

IC 263480 under ICR 202404-0938-015 · OMB 0938-1463.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Application to State Exchanges

Agency IC Tracking Number:

CCIIO - 10877

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.221(j)

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 114

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 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	114	114
Annual IC Time Burden (Hours)	20,706	20,706
Annual IC Cost Burden (Dollars)	1,480,882	1,480,882

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.