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) - Spanish	Form and Instruction	Modified	Available
Form CMS-10440 Application for Health Coverage & Help Paying Costs - Spanish	Form and Instruction	Modified	Available
Form CMS-10440 Application for Health Coverage & Help Paying Costs (Short Form) - Spanish	Form and Instruction	Modified	Available
Form CMS-10440 Electronic application.	Form	Modified	Available
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
Form CMS-10440 Individual Application	Form and Instruction	Modified	Repair queued
CMS-10440.Non-substantive change memo EOs 031425.docx	Supplementary Document	Uploaded 2025-04-18	Available
CMS-10440.Non-substantive change memo EOs 031425.docx	Supplementary Document	Uploaded 2025-04-18	Repair queued
CMS-10440.Non-substantive change memo .docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-09-27	Available
CMS-10440.Non-substantive change memo .docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-09-27	Repair queued
CMS-10440.Non-sub change Screenshot.docx	Supplementary Document	Uploaded 2024-09-27	Available
CMS-10440.Non-sub change Screenshot.docx	Supplementary Document	Uploaded 2024-09-27	Repair queued
CMS-10440 - Response to 60-day Comments.docx	Supplementary Document	Uploaded 2024-07-15	Available
CMS-10440 - Response to 60-day Comments.docx	Supplementary Document	Uploaded 2024-07-15	Repair queued
OMB 0938-1191 CMS-10440 Supporting Statement - Clean 031425 .docx	Supporting Statement A	Uploaded 2025-04-18	Available
OMB 0938-1191 CMS-10440 Supporting Statement - Clean 031425 .docx	Supporting Statement A	Uploaded 2025-04-18	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) - Spanish
205692	Individual Application	Form and Instruction	Modified	Application for Health Coverage & Help Paying Costs - Spanish
205692	Individual Application	Form and Instruction	Modified	Application for Health Coverage & Help Paying Costs (Short Form) - Spanish
205692	Individual Application	Form	Modified	Electronic application.
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	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1191	ICR Reference No: 202504-0938-017
Status: Historical Active	Previous ICR Reference No: 202409-0938-029
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: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/02/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/18/2025
Terms of Clearance: Prior to the next extension or revision of this ICR, the public burden statement on each instrument shall be updated to include language that provides all of the information required per 5 CFR § 1320.8(b)(3).

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2027	09/30/2027	09/30/2027
Responses	11,327,040	0	11,327,040
Time Burden (Hours)	7,105,452	0	7,105,452
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:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 16580	03/07/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 57417	07/15/2024
Did the Agency receive public comments on this ICR? Yes

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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, CMS-10440, 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) ,   Electronic application. ,   Application for Health Coverage & Help Paying Costs (Short Form) - Spanish ,   Application for Health Coverage & Help Paying Costs - Spanish ,   Application for Health Coverage (no cost help) - Spanish

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	11,327,040	11,327,040	0	0	0	0
Annual Time Burden (Hours)	7,105,452	7,105,452	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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:

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Annual Cost to Federal Government: $313,565

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: 04/18/2025

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