Information Collection Request

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

ICR 202506-0938-003 · OMB 0938-1191 · Historical Inactive

Forms and Documents
DocumentTypeStatusAvailability
Form CMS-10440 Application for Health Coverage (no cost help) - Spanish Form and Instruction Modified Repair queued
Form CMS-10440 Application for Health Coverage & Help Paying Costs - Spanish Form and Instruction Modified Repair queued
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 Repair queued
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
Att A.-Application PRA Electronic Application 022825 Clean.xlsx Supplementary Document Uploaded 2025-06-04 Repair queued
Att A.-Application PRA Electronic Application 022825 Clean.xlsx Supplementary Document Uploaded 2025-06-04 Repair queued
CMS-10440 Supporting Statement (proposed rule 9884-P).docx Supporting Statement A Uploaded 2025-06-04 Repair queued
CMS-10440 Supporting Statement (proposed rule 9884-P).docx Supporting Statement A Uploaded 2025-06-04 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
205692 Individual Application Form and Instruction ModifiedApplication for Health Coverage (no cost help) - Spanish
205692 Individual Application Form and Instruction ModifiedApplication for Health Coverage & Help Paying Costs - Spanish
205692 Individual Application Form and Instruction ModifiedApplication for Health Coverage & Help Paying Costs (Short Form) - Spanish
205692 Individual Application Form ModifiedElectronic application.
205692 Individual Application Form and Instruction ModifiedApplication for Health Coverage (no cost help)
205692 Individual Application Form and Instruction ModifiedApplication for Health Coverage & Help Paying Costs
205692 Individual Application Form and Instruction ModifiedApplication for Health Coverage & Help Paying Costs (Short Form)
205692 Individual Application Form and Instruction Modified
ICR Details
0938-1191 202506-0938-003
Historical Inactive 202504-0938-017
HHS/CMS CCIIO
Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and CHIP Agencies (CMS-10440)
Revision of a currently approved collection   No
Regular
Comment filed on proposed rule and continue 07/07/2025
Retrieve Notice of Action (NOA) 06/04/2025
In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OIRA a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.
  Inventory as of this Action Requested Previously Approved
09/30/2027 36 Months From Approved 09/30/2027
11,327,040 0 11,327,040
7,105,452 0 7,105,452
0 0 0

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.

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
  
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

0938-AV61 Proposed rulemaking 90 FR 12942 03/19/2025

No

No
Yes
Miscellaneous Actions
There is a total annual application processing burden increase of 2,554,446 hours (from 2,112,493 hours to 4,666,939 hours). The burden increase is due to the increase in consumers for whom the Exchange will need to adjudicate income inconsistencies and process SEP verification issues. There is a total annual consumer burden increase of 2,026,150 hours (from 4,992,959 hours to 7,019,109 hours). The burden increase is due to the increase in consumers who will need to gather and submit documents in order to adjudicate income inconsistencies and resolve SEP verification issues.

$3,629,229
No
    No
    No
Yes
No
No
No
Jamaa Hill 301 492-4190

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
06/04/2025