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

OMB 0938-1191

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.

The latest form for Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and CHIP Agencies (CMS-10440) expires 2022-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10440 Individual Application Form and Instruction
CMS-10440.Non-substantive change memo .docx Justification for No Material/Nonsubstantive Change
CMS-10440.Non-sub change Screenshot.docx Supplementary Document
CMS-10440 - Response to 60-day Comments.docx Supplementary Document
OMB 0938-1191 CMS-10440 Supporting Statementf.30 Day - Final.docx Supporting Statement A
Individual Application Form and Instruction

All Historical Document Collections

202409-0938-029	No material or nonsubstantive change to a currently approved collection	2024-09-27
202407-0938-009	Revision of a currently approved collection	2024-07-16
202405-0938-008 Approved without change	Revision of a currently approved collection	2024-05-08
202304-0938-028 Comment filed on proposed rule and continue	Revision of a currently approved collection	2023-04-28
202208-0938-007 Approved with change	Revision of a currently approved collection	2022-08-05
201903-0938-016 Approved without change	Revision of a currently approved collection	2019-04-08
201603-0938-021 Approved with change	Revision of a currently approved collection	2016-03-31
201302-0938-004 Approved with change	New collection (Request for a new OMB Control Number)	2013-02-05

OMB Details

Individual Application

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-10440	Electronic Questionnaire Additional Items	Fillable Fileable	Form and instruction
Form CMS-10440	Paper Application - non-FA, plus appendices	Fillable Fileable	Form and instruction
Form CMS-10440	Attachment C - Paper Application - FA Family, plus appendices	Fillable Fileable	Form and instruction
Form CMS-10440	CMS-10440 - Attachment A-Individual Online Application Questionnaire	Fillable Fileable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.