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

Document Name	Status
Form CMS-10440 Individual Application Form and Instruction	Modified
Att A.-Application PRA Electronic Application 022825 Clean.xlsx Supplementary Document	2025-06-04
CMS-10440 Supporting Statement (proposed rule 9884-P).docx Supporting Statement A	2025-06-04

IC Document Collections

IC ID	Document Title	Status
205692	Individual Application Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1191	ICR Reference No: 202506-0938-003
Status: Received in OIRA	Previous ICR Reference No: 202504-0938-017
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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/04/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	09/30/2027
Responses	800,467	11,327,040
Time Burden (Hours)	7,019,109	7,105,452
Cost Burden (Dollars)	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:
0938-AV61	Proposed rulemaking	90 FR 12942	03/19/2025

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

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

	Total Request	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	800,467	11,327,040	0	-10,526,573	0	0
Annual Time Burden (Hours)	7,019,109	7,105,452	0	-86,343	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: 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.

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Annual Cost to Federal Government: $3,629,229

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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