Information Collection

Application to State Exchanges

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

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Information Collection (IC) Details

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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:

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 %

	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

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.