Information Collection

Exchange Blueprint Application

IC 202391 under ICR 202508-0938-025 · OMB 0938-1172.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10416 Exchange Blueprint Application	Form and Instruction
Form CMS-10416 Blueprint for Approval of Affordable Healthcare Marketplaces Exchange Blueprint Application	Form and Instruction
CMS-10416 Blueprint for Approval of Affordable Healthcare Marketpl CMS-10416 - Blueprint Application.docx	Form and Instruction
CMS-10416 Blueprint for Approval of Affordable Healthcare Marketpl CMS-10416 - Blueprint Application.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.157 45 CFR 153 42 CFR 431, 435, and 457 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10416				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2	-2	4
Annual IC Time Burden (Hours)	107	-19	126
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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