Individual Application

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

OMB: 0938-1191

IC ID: 205692

Documents and Forms
Document Name
Document Type
Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form
Form
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Individual Application
 
No Modified
 
Required to Obtain or Retain Benefits
 
45 CFR Parts 155, 156, 157 26 CFR 1 and 602 42 CFR Parts 431, 435, 457  (To search for a specific CFR, visit the Code of Federal Regulations.)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10440 Application for Health Coverage & Help Paying Costs (Short Form) Att B-Individual-short-form-English clean FINAL.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10440 Application for Health Coverage & Help Paying Costs Att C-Marketplace-consumer-application-family-English-clean-Final.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10440 Application for Health Coverage (no cost help) Att D-Marketplace-application-without-financial-assistance-English clean FINAL.pdf Yes Yes Fillable Fileable
Form CMS-10440 Electronic application. CMS-10440 - Att A.-App3 PRA Electronic Application - Final.xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10440 Attachment B - Individual Short Form (Spanish) Att B-Individual-short-form-Spanish-clean_FINAL.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10440 Attachment C - Marketplace Consumer Application (Spanish) Att C-Marketplace-consumer-application-family-Spanish-clean FINAL.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10440 Attachment D - Marketplace Application without Financial Assistance (Spanish) Att D-Marketplace-application-without-financial-assistance_Spanish-clean FINAL.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

11,327,040 0
   
Individuals or Households
 
   90 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 11,327,040 0 0 6,296,040 0 5,031,000
Annual IC Time Burden (Hours) 7,105,452 0 0 4,759,453 0 2,345,999
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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