Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges (CMS-10371)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10371 SBM Three-Year Budget Template	Form and Instruction	Modified	Available
Form CMS-10371 SBM Three-year Budget Reports	Form and Instruction	Modified	Available
Form CMS-10371 SBM Individual Market Reporting	Form and Instruction	Modified	Available
Form CMS-10371 SBM Individual Market Reports (weekly)	Form and Instruction	Modified	Available
CMS-10371SBMBi-AnnualMetric.docx	Supplementary Document	Uploaded 2025-09-09	Available
CMS-10371 - Bi-Annual Metric.pdf	Supplementary Document	Uploaded 2025-06-04	Missing upstream
CMS-10371SBMMetrics-OE.docx	Supplementary Document	Uploaded 2025-09-09	Available
CMS-10371 - SBM Metrics.pdf	Supplementary Document	Uploaded 2025-06-04	Repair queued
CMS-10371SBEBudgetTemplate.xls	Supplementary Document	Uploaded 2025-09-09	Repair queued
CMS-10371SBEBudgetTemplate.xls	Supplementary Document	Uploaded 2025-06-04	Available
CMS-10371 - APPENDIX A.pdf	Supplementary Document	Uploaded 2025-06-04	Available
CMS-10371 - APPENDIX A.pdf	Supplementary Document	Uploaded 2025-06-04	Repair queued
CMS-10371 - SupportingStatement Final.docx	Supporting Statement A	Uploaded 2025-09-09	Available
CMS-10371 - Supporting Statement.docx	Supporting Statement A	Uploaded 2025-06-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
252604	State Based Marketplace Data Collection Templates for Bi-Annual Reporting	Other-Data Template	Modified
228022	SBM Three-year Budget Reports	Form and Instruction	Modified	SBM Three-Year Budget Template
228022	SBM Three-year Budget Reports	Form and Instruction	Modified
228019	SBM Individual Market Reports (weekly)	Form and Instruction	Modified	SBM Individual Market Reporting
228019	SBM Individual Market Reports (weekly)	Form and Instruction	Modified
216248	End of Enrollment Budget Report	Other-Data Elements	Modified

ICR Details

OMB Control No: 0938-1119	ICR Reference No: 202506-0938-001
Status: Historical Active	Previous ICR Reference No: 202404-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No: CCIIO
Title: Cooperative Agreement to Support Establishment of State-Operated Health Insurance Exchanges (CMS-10371)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/12/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/04/2025
Terms of Clearance: Before submitting this package for revision or extension the agency will consider the possible addition of data elements covering complaint disposition and median cost to process activities like appeals, complaints, DMIs, etc. Additionally, the agency will consider publishing additional data elements from the bi-annual report on the agency’s public-facing website. Supporting Statement A shall be updated to reflect these considerations.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2028	36 Months From Approved
Responses	363	0	0
Time Burden (Hours)	7,306	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Information collected as a part of the application for this grant will be used to evaluate the applications and determine awardees. Information collected pursuant to the reporting requirements for awardees will be used to evaluate the progress of States in planning for and implementing Exchanges, and determine how the Secretary can provide assistance to achieve the goals of the grant program and the Affordable Care Act.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 1311 Name of Law: Affordable choices of health benefit plans
  

Citations for New Statutory Requirements: None

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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 95217	12/04/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 21775	05/21/2025
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
End of Enrollment Budget Report
SBM Individual Market Reports (weekly)	CMS-10371	SBM Individual Market Reporting
SBM Three-year Budget Reports	CMS-10371	SBM Three-Year Budget Template
State Based Marketplace Data Collection Templates for Bi-Annual Reporting

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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	363	0	0	90	0	273
Annual Time Burden (Hours)	7,306	0	0	4,485	0	2,821
Annual Cost Burden (Dollars)	0	0	0	-1,251,236	0	1,251,236

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The number of respondents has been adjusted. CMS accounted for an increase in the number of SBE and SBE-FPs (from 21 to 23), which increased the total annual burden hours for the four reports remaining in this package from 2,821 to 7,306.

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Annual Cost to Federal Government: $79,956

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: 06/04/2025

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